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Human enhancement and the future of work Report from a joint workshop hosted by the Academy of Medical Sciences, the British Academy, the Royal Academy of Engineering and the Royal Society.

November 2012

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ISBN No: 978-1-903401-35-4

Human enhancement and the future of work

Report from a joint workshop hosted by the Academy of Medical

Sciences, the British Academy, the Royal Academy of Engineering

and the Royal Society.

November 2012

Acknowledgements and disclaimerCognisant of the lack of debate about the potential impact of human enhancement in the

workplace, the Academy of Medical Sciences, British Academy, Royal Academy of Engineering and

Royal Society came together to consider the implications of human enhancement technologies for

the future of work. The Academies convened a small policy-focused workshop on 7 March 2012,

which brought together policy-makers with leading experts from across engineering, science, social

science, the humanities and industry. The Academies are very grateful to the steering committee,

chaired by Professor Genevra Richardson CBE FBA, which has overseen this project. This is the first

time that these four academies have combined their expertise to consider the policy implications of

developments in a diverse range of research fields.

This report captures the themes and questions that emerged from the workshop and does not

necessarily represent the views of the four host academies.

All web references were accessed in October 2012.

© The Academy of Medical Sciences

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CONTENTS

Contents

Summary 5

1 Introduction 9

2 Cognitive enhancement 13

3 Physical enhancement 23

4 Commercialisation opportunities and challenges 33

5 Potential implications for the future of work 37

6 Policy and regulatory implications 49

7 Conclusion 53

Annex I Workshop programme 55

Annex II Steering committee membership 57

Annex III Workshop participants 59

Glossary 61

4

HUMAN ENHANCEMENT AND THE FUTURE OF WORK

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Over the next few decades, the nature of paid

work is likely to change significantly owing,

for example, to the ageing workforce and

changing working practices. Although human

enhancement technologies might aid society in

dealing with this transition, their use at work is

likely to have implications that require careful

consideration, particularly by policy-makers,

employers, employees, researchers and wider

society. Any such use would have impacts

across the population and on individuals

both employed and not employed. Human

enhancement has been widely debated and

discussions usually focus on the desire to

improve performance. Although the context

of work is clearly a primary application of

these technologies, debate around human

enhancement has not specifically considered

the context of work.

Cognisant of the lack of debate about the

potential impact of human enhancement in the

workplace, the Academy of Medical Sciences,

British Academy, Royal Academy of Engineering

and Royal Society jointly hosted a workshop to

consider this topic on 7 March 2012. Human

enhancement refers to endeavours that

are designed or used to restore or improve

human performance, thus overcoming the

current limits of one’s human body (see Box

1). This workshop was concerned with novel

technologies that have the potential to extend

an individual’s capacities beyond their current

limits. This interdisciplinary workshop brought

together policy-makers with leading experts

from across engineering, science, social science,

the humanities and industry. The workshop

provided insights into enhancements that might

arise from advances in science and engineering

that are likely to impact on the future of work,

and it considered the associated opportunities

and challenges for all stakeholders and for

policy in particular. To capture the range of

future technologies most accurately, the

workshop primarily focused on technologies

likely to impact on work in the next decade.

A fundamental aspect of this discussion relates

to the ultimate objective of enhancement.

Potential outcomes exist along a spectrum,

from increasing participation in work among

those who might otherwise be disadvantaged

or excluded, to improving the performance

and efficiency of all employees beyond the

current limits of human capacity. Any effective

regulatory framework would need to reflect

these different objectives. Attention also needs

to be given to the risk that people will be put

under pressure to enhance their ability to

tolerate demanding work such as shift working;

this risk will be greatest for those with the

weakest labour market conditions. Attendees

were keen to stress that these technologies are

not a substitute for improving conditions

of work.

This report outlines selected developments

from across science and engineering that

could enable both cognitive and physical

enhancement, although it is not exhaustive.

It summarises the themes and issues raised

during the workshop. Given that there is

currently little debate about the use of

enhancements at work or an academic research

base to draw upon, the report aims to highlight

possible implications of such use, which are

likely to be complex, and to identify potential

areas for debate. Key messages identified by

workshop participants include the following:

• Enhancement technologies could change how people work. Work

will evolve over the next decade, with

enhancement technologies potentially

making a significant contribution.

Widespread use of enhancements might

influence an individual’s ability to learn or

perform tasks and perhaps even to enter

a profession; influence motivation; enable

people to work in more extreme conditions

or into old age, reduce work-related illness;

or facilitate earlier return to work

after illness.

SUMMARY

Summary

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• Implications will be complex and there will be multiple political and social tensions. There are many instances where

the possible implications of enhancement

at work will be complex and potentially

divisive. Enhancement could benefit

employee efficiency and even work–life

balance, but there is a risk that it will

be seen as a solution to increasingly

challenging working conditions, which could

have implications for employee wellbeing.

Enabling an ageing workforce to delay

retirement would have implications for

youth employment.

• The distinction between enhancement and restoration is difficult. The

workshop aimed to consider enhancement

technologies as both restorative and

taking individuals ‘beyond the norm’.

Although ‘norm’ is a challenging concept,

this distinction may be integral to

considerations of the acceptability of

new technologies, and thus to regulatory

decisions. The use of restorative

technologies might facilitate a diminishing

of the line between the disabled and the

non-disabled with both negative and

positive consequences.

• The use of enhancements will vary with context. Usefulness will vary

between individuals and occupations. In

addition, work will evolve over the next

decade and beyond, and this will influence

the role that enhancements play in the

future. To maximise any benefit from

enhancement technologies, we must

understand the complexities of these

context-specific outcomes and involve

individuals in the design and integration

of technologies, and in the design of any

regulatory frameworks.

• It is helpful to identify whether issues are unique to human enhancement. If the issues raised are familiar, we must

identify relevant contexts from which we

can learn. In cases where unprecedented

concerns exist, careful consideration and

wider dialogue will be important.

• A range of policy questions will need to be addressed. Although enhancement

technologies might bring opportunities,

they also raise several health, safety,

ethical, social and political challenges,

which warrant proactive discussion. Very

different regulatory regimes are currently

applied: for example, digital services

and devices (with significant cognitive

enhancing effects) attract less, if any,

regulatory oversight than pharmacological

interventions. This raises significant

questions, such as whether any form of

self-regulation would be appropriate and

whether there are circumstances where

enhancements should be encouraged or

even mandatory, particularly where work

involves responsibility for the safety of

others (e.g. bus drivers or airline pilots).

• Empirical data are needed to guide policy. ‘Known unknowns’ need to be

addressed by studies on short- and long-

term impacts (both positive and negative)

of enhancements on individuals with

detailed consideration of social and ethical

impacts using deliberative dialogue with

users, potential users and wider society and

the development of a market map to guide

commercialisation. Continuous monitoring

to inform the re-assessment of any policy

or regulatory decisions is vital but will also

require these underpinning data.

• Policy must be informed by open dialogue. We must engage publics in

open dialogue about the prospects of

enhancement technologies and how they

might be used at work, particularly given

that use at work would affect the entire

population, both those employed and

not employed. Sources of input should

include users of enhancements, older

populations, trade unions, as well as those

with expertise with novel innovations

and technologies. Policy-makers and

publics must be equipped to recognise

circumstances in which, for example, claims

around the benefits of new technologies

are inflated.

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• The cost of technologies will be

crucial. Cost and cost–benefit analysis

are clearly key factors in determining who

funds provision, which in turn will impact

on equality and justice. Cost also drives

investment decisions and will therefore be

important in determining commercialisation

opportunities.

• Development of enhancement

technologies might offer economic

opportunities. There may be an

opportunity to create a new human

enhancement industry in the UK; bringing

together the UK’s leading innovators in

the fields of physics, biology, chemistry,

engineering and design in addition to

the application of enhancements to

employees working within current UK

industries to increase the competitiveness

of the workforce.

• The international aspect of

enhancement is inescapable. Regulation

will need to be sensitive to technological

development and international competition,

both in terms of developing technologies

and using them to improve performance.

• The availability of enhancements will be influential. Although the cost of some

enhancement technologies will render

them inaccessible to all but the very few,

raising questions of equality and justice,

other technologies such as pharmacological

cognition enhancers, are already readily

available through the internet—posing

imminent challenges for effective

regulation. Likewise, digital devices and

services with the potential to influence

cognition are emerging continuously with

little research into the risks and benefits.

• Interdisciplinary approaches will be key to moving forward. In

developing new technologies, whether

they are cognitive training or bionic

limbs, interdisciplinary approaches will

facilitate better understanding of how

best to proceed. This also applies to

implementation: if any enhancement is

seen as valuable, scientists need to work

together with social scientists, philosophers,

ethicists, policy-makers and the public to

discuss the ethical and moral consequences

of enhancement, and thus to harness

maximum benefit with minimal harm.

SUMMARY

Box 1 What is meant by human enhancement?

The term ‘human enhancement’ encompasses a range of approaches that may be used to

improve aspects of human function (e.g. memory, hearing, mobility). This may either be for

the purpose of restoring an impaired function to previous or average levels, or to raise

function to a level considered to be ‘beyond the norm’ for humans.

This is often achieved through technological means, with examples including the following:

• The use of cognitive enhancing drugs to improve memory and concentration.

• The use of hearing aids and retinal implants to improve sensory perception.

• The use of bionic limbs to restore mobility.

These examples demonstrate that new enhancement techniques arise from a range of

disciplines including biotechnology, engineering, neuroscience and computing. The social,

political, ethical, economic and regulatory issues raised by their use further highlight the

interdisciplinary nature of this topic.

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Human enhancement refers to endeavours

that are designed or used to restore or improve

human performance, thus overcoming the

current limits of one’s human body. Advances

in fields such as biotechnology, engineering,

neuroscience and computing bring the potential

for novel enhancement technologies that could

have significant implications for individuals

and society. The development and use of these

enhancements raise a range of scientific,

engineering, social, political, ethical, economic

and regulatory issues. In using the term

‘enhancement’ throughout this report we do

not intend to imply that a consensus exists on

how and whether humans might be ‘improved’

or that there will only be positive outcomes to

any enhancement. Alternative terms such as

‘modulation’ have been suggested and there

is merit in considering such alternatives

as debate about the application of these

technologies progresses.

The UK will see significant changes to its

demographics over the next decade and beyond.

For example, there are currently 10 million

people in the UK who are over 65 years old.

It is estimated that this figure will rise by

approximately 5.5 million over the next 20

years and almost double to around 19 million

by the year 2050.1 Demographic shifts will be

accompanied by changes to the nature of work,

and both of these transitions will influence the

context in which enhancements might be used.

The workshop focused primarily on paid work,

rather than domestic and unpaid labour that

often provide vital care functions. Box 2 outlines

some of the ways in which the nature of paid work

might change over the next decade and beyond.

The joint academies’ workshop was concerned

with novel technologies that have the potential

to extend an individual’s capacities beyond

their current limits. This working definition

encompasses restorative enhancements and

those that could take individuals ‘beyond

the norm’, by which we mean both beyond

an individual’s ‘norm’ and beyond the ‘norm’

of current human limits.2 In considering

implications for the future of work, we felt it

important to include the whole spectrum of

enhancement technologies.

In considering the application of human

enhancement to work, much discussion at

the workshop focused on its potential role in

increasing the access of disabled people to

work. The Department of Work and Pensions

has estimated that there are over 10 million

disabled people in the UK.3 Over 6 million

report significant problems with mobility, a

similar number with lifting and carrying, and

over 2 million report problems with dexterity

and/or coordination. Of the people living with

disabilities, about 50% are of working age.

However, employment rates among individuals

with a disability that limits their daily activities

(DDA disabled) are well below the national

average for those who are not DDA disabled

(45.6% compared with 76.2%), with the

lowest rates for those with depression, mental

illness and learning difficulties.4 The use of

enhancement technologies that restore capacity

could therefore have significant implications for

this community, and, commonly, technologies

used to enhance healthy individuals often

emerge from those that were originally designed

to be restorative.

1 INTRODUCTION

1 Introduction

1 Cracknell R (2010). The ageing population. http://www.parliament.uk/documents/commons/lib/research/key_issues/Key%20Issues%20The%20ageing%20population2007.pdf

2 Defining the ‘norm’ is complex. For example, in the elderly, cognition may be normal for the age but cognitive performance may have declined from performance when young. Additionally, for example, in spectrum disorders, extreme conditions may be clearly diagnosable but those on the borderline may blend with healthy controls (e.g. as for attention-deficit–hyperactivity disorder).

3 Office for Disability Issues, Department of Work and Pensions (2001). Disability prevalence estimates 2009/10. http://odi.dwp.gov.uk/docs/res/factsheets/disability-prevalence.pdf

4 Office for National Statistics (2011). People with disabilities in the labour market – 2011. http://www.ons.gov.uk/ons/dcp171776_242963.pdf

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Our working definition includes all forms of

enhancement that directly alter the individual,

but excludes the wider environment, i.e.

alterations to the environment itself that

enhance human interactions with it. There are

interesting developments in efforts to enhance

the environment in which people work, and

moves towards assisted living (i.e. assistance

with the activities of daily living) bring technical

interventions that could allow people to stay

in their own home for longer, particularly in

old age. However, these were outside of the

remit of this particular workshop. Education

is relevant in its role in preparing individuals

for work and ongoing training throughout the

life course (e.g. lifelong learning), but was not

considered a focus of this meeting.

This report seeks to capture the themes and

questions that emerged from the workshop

and does not necessarily represent the views

of the four host academies. The report will

be of interest to policy-makers, researchers

in science and engineering, experts in the

social sciences and humanities, research

funders, industry, investors and publics, both

within the UK and internationally. Chapters

2 and 3 explore the science and engineering

developments that could give rise to physical

and cognitive enhancement. Opportunities

and challenges relating to investment and

commercialisation are outlined in Chapter 4.

Chapter 5 discusses possible implications for

the future of work and society. Potential policy

and regulatory implications are considered

in Chapter 6.

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1 INTRODUCTION

Box 2 Examples of potential changes to the nature of work in future

Composition and diversity of the workforceOwing to the ageing population, we are likely to see individuals working at an older age,

resulting in a more multigenerational workforce. Different generations are likely to have

different attitudes towards, and experiences of, technology. Further changes to, for example,

gender balance and migration, will combine to generate additional diversity.

Working practicesWorkers are likely to have increasing expectations of, and access to, flexible working. This

might be in terms of working hours, location and further changes to the global nature of

business and work.

Evolving nature of workThe UK has seen a transition from the production of goods to the provision of information and

services, which is set to continue. Different skills will be expected from employees, which could

impact on health and safety, such as the nature of work-associated illnesses.

EconomicsGlobal economies will be in recovery for several years. We are likely to see further growth in

international competition and evolution of the form and structure of organisations.

Disease trendsThe conditions that will have greatest impact on the working population will be musculoskeletal

disorders and mental illness. Sensory disorders will remain prevalent and lifestyle diseases will

continue to rise. As the nature of, and attitudes towards, illnesses change, and as medicine

progresses, it will become much more likely that individuals will work while in ill health or

with disabilities.

The role of workWork is increasingly seen as a source of wellbeing. Being in work is beneficial to physical and

mental wellbeing. Employers are assuming a greater degree of responsibility for the welfare of

their employees and are well placed to promote a healthy lifestyle among workers.

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13

2 COGNITIVE ENHANCEMENT

2 Cognitive enhancement

Overview

There are several ways to enhance cognition in humans. Education and physical exercise

are two well-established cognition enhancers not considered in detail here. Over the next

decade, the ageing population will render efforts to restore and maintain cognition increasingly

important. Emerging approaches include the following:

• Cognition enhancing drugs used to treat individuals with neuropsychiatric disorders

could also improve mental faculties such as memory and concentration in healthy

individuals, enabling them to work more efficiently or for longer.

• Drugs could also facilitate cognitive maintenance, which could be particularly beneficial

to the ageing workforce. Revealing the optimal timing of treatment onset, as well as the

risk factors that could facilitate cognitive decline, will be invaluable.

• Cognitive training delivered by computer may be able to improve learning, and research

into the ways in which the brain responds to training is beginning to inform software design.

Cognitive training will be most useful if it can provide transferable improvements, rather

than just better performance on specific tasks.

• Brain stimulation, particularly non-invasive techniques, might facilitate improved learning

and training outcomes, but further research will be needed to reveal how it should be used.

• Collective cognition could also facilitate enhanced performance at work. The rise in

ubiquitous communications technologies over the past decade has changed how we work

and is likely to improve efficient and inexpensive coordination and knowledge-sharing. This

brings new opportunities to harness technology to boost the power of a collective network

to solve complex problems. Individuals will in turn use the outputs of collective efforts to

enhance their individual performance.

Pharmacological cognitive enhancement

Recent developments in our approaches to

neuroscience and mental health policy have

seen a shift in focus from attempts to treat

chronic, relapsing mental health disorders to

the prevention and early detection of such

disorders.5 Research focuses on successful

and resilient neurodevelopment.6 Participants

emphasised that preserving mental wellbeing

in this way is important to enabling people

to stay in work. This was a key feature of the

2008 Foresight project on ‘Mental Capital and

Wellbeing’ by the UK Government Office

for Science.7

Cognitive maintenance and restoration

Research on degenerative diseases such as

dementia reflects a shift in focus to prevention.

Life expectancy increases linearly by two years

every decade.8 There are currently 820,000

people with dementia in the UK and this is

expected to double over the next 30 years.9

5 Beddington J, et al. (2008). The mental wealth of nations. Nature 455, 1057–1060.6 Sahakian BJ, Malloch G & Kennard C (2010). A UK strategy for mental health and wellbeing. Lancet 375, 1854–1855.7 Foresight Mental Capital and Wellbeing Project (2008). Final project report – executive summary. The Government Office for Science,

London.8 Population Reference Bureau (2006). The future of human life expectancy: have we reached the ceiling or is the sky the limit?

www.prb.org/pdf06/NIA_FutureofLifeExpectancy.pdf9 Alzheimer’s Research Trust (2010). Dementia 2010: the economic burden of dementia and associated research funding in the United

Kingdom. http://www.dementia2010.org/reports/Dementia2010Full.pdf

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Current medications such as cholinesterase

inhibitors target disease symptoms with the

aim of delaying cognitive decline. However,

novel medications that improve episodic

memory more effectively, and neuroprotective

medications, are needed. New approaches

target the molecular pathways, such as the

amyloid cascade in the brain, or the formation

of insoluble tau protein, but we are yet to find a

treatment that truly modifies the degeneration.

It may be that the hypotheses relating to

disease processes need to be reconsidered,

as other factors, such as inflammation, may

be more important than previously thought.

However, Professor John O’Brien, Professor of

Old Age Psychiatry at Newcastle University,

told the workshop that there is a growing

consensus that we are currently identifying

and treating patients at too late a stage. It is

likely that there is a 10–20 year asymptomatic

stage before disease onset; targeting this

might hold the key to improving methods

of cognitive maintenance. This theory not

only reflects our greater understanding of

molecular mechanisms causing dementia but

also how risk factors such as diet and activity

and vascular risk during middle age affect

health later in life; we must understand the

risk factors for cognitive decline to improve our

management of it. Professor O’Brien reported

that patients seek disease stabilisation and

cognitive maintenance. In moving forward,

research must firstly look to further our

understanding of the fundamental science

of neurodegeneration, and secondly reveal

the optimal timing for the delivery of such

treatments, which will depend on whether

they seek to prevent the underlying molecular

changes, or modify risk factors.

Cognitive-enhancing drugs have not only

been developed for the treatment of

neurodegenerative diseases, but also for other

neuropsychiatric disorders, including attention-

deficit–hyperactivity disorder (ADHD) and

schizophrenia. Such disorders are characterised

by cognitive manifestations including

attentional biases, aberrant learning, memory

impairments, dysfunctional reward systems

and a lack of top-down cognitive control by the

prefrontal cortex.10 Professor Barbara Sahakian

FMedSci, Professor of Clinical Neuropsychology

at the University of Cambridge, told the

workshop that it is most often the decline in

these cognitive abilities that inhibits individuals

with depression or schizophrenia from returning

to work.11,12 Cognitive enhancers can treat

cognitive disabilities and improve mental capital

and wellbeing, but also an individual’s quality of

life and their ability to work.13

The annual costs of these kinds of disease,

including those related to lost earnings

and lost productivity, mean that there are

economic benefits to effective treatment of all

neuropsychiatric disorders. It is estimated that

by 2026, the cost of mental health disorders

in England will rise to £88.4 billion, nearly half

of which will be as a result of lost earnings

(£40.9 billion).14

Cognitive enhancement of healthy individuals

Box 3 outlines the kinds of cognitive enhancer

on the market. Professor Sahakian reported

that we are increasingly seeing some of these

drugs used by healthy individuals, among

whom there is evidence that they do improve

10 Sahakian BJ (2011). American College of Neuropsychopharmacology 50th Annual Meeting, 4 December 2011.11 Scoriels L, et al. (2012). Effects of modafinil on cognitive functions in first episode psychosis. Psychopharmacology 220(2), 249–258.12 Clark L, Chamberlain SR & Sahakian BJ (2009). Neurocognitive mechanisms in depression: implications for treatment. Annual Review of

Neuroscience 32, 57–74.13 Morein-Zamir S & Sahakian BJ (2011). Pharmaceutical cognitive enhancement. In Illes J & Sahakian BJ, eds. (2011) Oxford Handbook of

Neuroethics. Oxford University Press, Oxford UK.14 King’s Fund (2008). Paying the Price: The cost of mental health care in England to 2026.

http://www.kingsfund.org.uk/publications/paying_the_price.html

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performance. For example, methylphenidate

improves short-term (or working) memory in

healthy volunteers, as well as in those with

ADHD.15,16 It also increases the ‘efficiency’

of the prefrontal cortical network in healthy

volunteers.17 Furthermore, stimulant drugs

exert their effects in a baseline-dependent

manner, so stimulants will improve low

performance in individuals regardless of

whether the individual is a healthy volunteer or

has ADHD.18 It has been shown that modafinil

improves planning in healthy volunteers.19

Research has explored whether cognitive

enhancers might be of use in workers who

are sleep deprived. A 2011 study found that

modafinil reduces impulsive behaviour and

improves cognitive flexibility in sleep-deprived

doctors.20 This group of individuals often use

caffeine to improve alertness, which in higher

doses is accompanied by side effects such as

tremor and heart palpitations. These effects are

not seen with modafinil.

Several surveys have investigated trends

in the use of cognitive enhancers among

student populations, with varying results, but

Professor Sahakian reported that 16% may be

a realistic estimate for the prevalence of use

among students in the USA.21 There is also

evidence that use among healthy individuals

is rising among school students, and stimulant

prescription rates in England have been rising

steadily from 220,000 in 1998 to 418,300

in 2004.22 Research indicates that some

academics also make use of enhancers such as

modafinil and for a variety of reasons, e.g. to

overcome jetlag and to improve productivity

for particularly challenging tasks.23 An online

poll by the journal Nature found that of 1,400

respondents from 60 countries, one in five said

they had used drugs for non-medical reasons

as a cognitive enhancer.24

The Royal Society concluded in 2011 that

education is the ‘most broadly and consistently

successful cognitive enhancer’.25 However, the

attraction of cognitive enhancement might lie

in gaining a small but significant competitive

edge. The Academy of Medical Sciences reported

in 2008 that small percentage increments

in performance can lead to significant

improvements in functional outcome; it is

conceivable that a 10% improvement in memory

score could lead to an improvement in an A-level

grade or degree class.26 The attraction may also

stem from the increased pleasure experienced

in performing a task. There is evidence that

cognitive-enhancing drugs such as modafinil

can increase motivation and the pleasure

gained from performing routine cognitive tasks,

compared with placebo.27


15 Elliott R, et al. (1997). Effects of methylphenidate on spatial working memory and planning in healthy young adults. Psychopharmacology 131, 196–206.

16 Turner DC, et al. (2005). Neurocognitive effects of methylphenidate in adult attention-deficit/hyperactivity disorder. Psychopharmacology 178, 286–295.

17 Mehta MA, et al. (2000). Methylphenidate enhances working memory by modulating discrete frontal and parietal lobe regions in the human brain. The Journal of Neuroscience 20, RC65.

18 Del Campo N, Müller U & Sahakian BJ (2012). Neural and behavioral endophenotypes in ADHD. Current topics in Behavioural Neurosciences 11, 65–91.

19 Turner DC, et al. (2003). Cognitive enhancing effects of modafinil in healthy volunteers. Psychopharmacology 165, 260–269.20 Sugden C, et al. (2011) Effect of pharmacological enhancement on the cognitive and clinical psychomotor performance of sleep-deprived

doctors: a randomized controlled trial. Annals of Surgery 255, 222–227.21 Babcock Q & Byrne T (2000). Student perceptions of methylphenidate abuse at a public liberal arts college. Journal of American College

Health 49, 143–145.22 Parliamentary Office of Science and Technology (2007). Better brains. http://www.parliament.uk/briefing-papers/POST-PN-285.pdf23 Morein-Zamir S & Sahakian BJ (2007). Professor’s little helper. Nature 450, 1157–1159.24 Maher B. (2008). Poll results: look who’s doping. Nature 452, 674–675.25 Royal Society (2011). Brain waves module 2. Neuroscience: implications for education and lifelong learning.

http://royalsociety.org/uploadedFiles/Royal_Society_Content/policy/publications/2011/4294975733.pdf26 Academy of Medical Sciences (2008). Brain science, addiction and drugs. http://www.acmedsci.ac.uk/download.php?file=/images/

publication/Report.pdf 27 Müller U, et al. (2012) Effects of modafinil on non-verbal cognition, task enjoyment and creative thinking in healthy volunteers.

Neuropharmacology, http://dx.doi.org/10.1016/j.neuropharm.2012.07.009

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However, it is not clear that such enhancers

will benefit all types of work. For example,

participants at the workshop discussed how

the effects on creativity are not clear. Research

yields mixed results, but there is evidence

that, for at least some cognitive-enhancing

drugs, such as stimulants, effects might depend

on the baseline creativity of an individual:

increasing it in lower performing individuals,

but inhibiting creativity in naturally high

performing individuals.31 It is likely that some

enhancements will be more useful to some

types of worker, for example shift workers,

and that there will be individual differences in

the effects of each enhancement. Where drugs

are concerned, in future it might be possible to

use techniques such as pharmacogenomics to

determine which individuals might benefit from

the use of specific cognitive-enhancing drugs.

Cognitive enhancers are a significant area

for pharmaceutical investment. As our

understanding of the brain improves, it may

inform the development of new enhancers,

for example the synaptic changes required for

memory encoding.

Non-pharmacological cognitive enhancement

Brain stimulation

There are also several non-pharmacological

options for enhancing cognition. Deep

brain stimulation has offered very effective

symptomatic relief in some patients with

Parkinson’s disease, and the technique

may have potential in treatment-resistant

depression.32 However, such an invasive

technique is unlikely to have widespread

applications. Dr Roi Cohen Kadosh, Wellcome

Research Career Development Fellow at the

University of Oxford, told the workshop that

non-invasive brain stimulation could be a

28 Royal Society (2011). Brain Waves module 1. Neuroscience, society and policy. http://royalsociety.org/uploadedFiles/Royal_Society_Content/policy/publications/2011/4294974932.pdf

29 Chamberlain SR, et al. (2007). Atomoxetine improved response inhibition in adults with attention deficit/hyperactivity disorder. Biological Psychiatry 62, 977–984.

30 Scoriels L, Jones PB & Sahakian BJ (2012). Modafinil effects on cognition and emotion in schizophrenia and its neurochemical modulation in the brain. Neuropharmacology. http://dx.doi.org/10.1016/j.neuropharm.2012.07.011

31 Farah MJ (2008). When we enhance cognition with Adderall, do we sacrifice creativity? A preliminary study. Psychopharmacology 202, 541–547.

32 Holtzheimer PE (2012). Subcallosal cingulate deep brain stimulation for treatment-resistant unipolar and bipolar depression. Archives of General Psychiatry 69, 150–158.

Box 3 Examples of cognitive enhancers currently in common use

Methylphenidate (Ritalin) increases the synaptic concentration of the neurotransmitters

dopamine and noradrenaline by blocking their reuptake.

Atomoxetine (Strattera) is a relatively selective noradrenaline reuptake inhibitor. Although

Ritalin has low abuse potential when prescribed correctly, its action on the dopaminergic

system brings a risk of substance misuse. By not acting on dopamine, Atomoxetine is not

accompanied by such risks.

Modafinil (Provigil) is an atypical stimulant. Its cognitive enhancing effects are likely to be

due to effects on noradrenaline and possibly dopamine.

Some cognitive-enhancing drugs do not produce extreme changes in mood that usually

accompany recreational use, such as a ‘high’ or ‘rush’, and do not lead to obvious physical

dependence.28 This applies to drugs such as atomoxetine and modafinil.29,30

CHAPTER TITLE

17

more applicable technique and of widespread

use in the next years. The most used non-

invasive transcranial stimulation methods

are transcranial magnetic stimulation, in

which a magnetic coil is placed above part

of the skull to deliver magnetic pulses to

the brain area beneath the skull, and to

induce action potentials; and transcranial

electrical stimulation, in which low electrical

currents are applied to the skull through one

or more electrodes, to modulate neuronal

excitability in brain areas beneath the skull.

Transcranial electrical stimulation offers the

most possibilities for cognitive enhancement at

home, office, clinics and educational institutes

as it is a relatively inexpensive, portable and

painless method of enhancing cognitive abilities

by modulating brain activity. Currently the data

from low electrical stimulation studies do not

reveal any risk or major side effects. There

is evidence that transcranial direct electrical

stimulation shows potential in enhancing the

learning and cognition of healthy adults and

those with neurological impairment, and its

effects could be relatively long-term in nature

(e.g. between six and twelve months after

treatment).33,34,35,36 More research is required

to establish how useful it might be, especially

in the elderly and in children with atypical

development, where experimental evidence is

relatively scarce. It is also not clear whether

improvements in performance are transferred to

other tasks, and research is required particularly

to determine optimal use, which might differ for

different populations, for example:

• Point at which the technique should be used

during learning.

• Duration, number of repetitions and timing

of stimulation (e.g. before or during the task).

• Position on the skull for the apparatus to be

placed and whether this is task-dependent.

• Intensity of stimulation and whether this

varies, for example between tasks.

As well as stimulating the brain, monitoring its

activity may offer new opportunities to restore

brain function in some disorders. Participants

noted that methods in neurofeedback are being

explored for the treatment of several cognitive

disorders. The technique makes use of sensors

placed on the scalp to record central nervous

system activity (e.g. by electroencephalography

or functional magnetic resonance imaging

(fMRI)), which provide immediate feedback

about brain activity in a way that can be used

to modulate training and deliver improvements

in physical, emotional or cognitive states.

Research suggests that neurofeedback is

an effective intervention to address the

inattention, impulsivity and hyperactivity

experienced by patients with ADHD and may

have applications to other disorders, including

Parkinson’s disease and schizophrenia.37,38,39

Cognitive training

Another way in which technology could support

the development of cognitive capabilities

is through cognitive training. More efficient

learning could be of value in the education

and training that prepare individuals to work

and enable ongoing improvement. Workshop

participants highlighted particular examples

that will be increasingly important as the

nature of work changes, such as language

learning. Dr Paul Howard-Jones, Senior Lecturer

in Education at the University of Bristol,

told the workshop that there are three key

characteristics of digital technology that make it


33 Cohen Kadosh R, et al. (2010). Modulating neuronal activity produces specific and long lasting changes in numerical competence. Current Biology, 20, 2016–2020.

34 Dockery CA, et al. (2009). Enhancement of planning ability by transcranial direct current stimulation. The Journal of Neuroscience, 29, 7271–7277

35 Holland R, et al. (2011). Speech facilitation by left inferior frontal cortex stimulation. Current Biology 21(16), 1403–1407.36 Fridriksson J, et al. (2011). Transcranial direct current stimulation improves naming reaction time in fluent aphasia: a double-blind,

sham-controlled study. Stroke 42(3), 819–821.37 Arns M, et al. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity:

a meta-analysis. Clinical EEG and Neuroscience 40, 180–189.38 Subramanian L, et al. (2011). Real-time functional magnetic resonance imaging neurofeedback for treatment of Parkinson’s disease.

The Journal of Neuroscience 31, 16309–16317.39 Ruiz S, et al. (2011). Acquired self-control of insula cortex modulates emotion recognition and brain network connectivity in schizophrenia.

Human Brain Mapping doi: 10.1002/hbm.21427.

18


well-suited to supporting cognitive training:

• It is adaptive: technologies can be

programmed to tailor experiences to

the individual.

• It is responsive: technologies can provide

immediate feedback.

• It is patient: activities can be

repeated limitlessly.

Two main types of initiative look to enable brain

training. Commercial ‘brain training’ software

targets multiple faculties, including memory

(short term, visuospatial or episodic), executive

control (attention switching) and visuomotor

skills. Laboratory studies normally make use of

bespoke software and specifically target working

memory. Although commercial training software

is generally unevaluated, there is growing

evidence that software used in laboratory

studies can improve cognition. However,

generating improvements that are transferable

to tasks that have not been the focus of training

presents a significant challenge.

These technologies, particularly those that

are commercially available, target multiple

audiences, from young to old and including

those with and without cognitive impairment.

Research indicates that cognitive training might

support cognitive maintenance. One study

found improvements in memory, reasoning and

speed of processing in individuals over 65 years

of age.40 However, this was not transferred

to a measurable improvement in real-life

tasks, although there were fewer self-reported

difficulties after the trial. Other studies have

indicated that such transfer might be possible.

Improvements in performance on cognitive

tasks within this same age group have been

reported, which subsequently translated into

improvements on generalised measures of

memory and attention, for which participants

had not been trained.41 Small-scale studies also

indicate that regularity may aid effectiveness:

elderly participants playing training games for

15 minutes per day for at least five days a week

saw improvements in executive functions and

processing speed.42 In fact, regular training

may improve executive functions across all age

groups in a transferable manner.43

The key to improving training methods again

lies in embracing a new approach: a new

science of learning, in which interdisciplinary

collaboration is essential to maximising the

potential of cognitive training.44 Psychology,

neuroscience, education and the use of

machine learning must all interact to generate

an iterative design loop where, for example,

neuroscience provides insights that inform

the development of technologies, which

then provide a platform on which further

neuroscience studies can be performed.

Although such collaborations are still at a very

early stage and can yield apparently conflicting

findings, studies are beginning to offer insights

into the underlying neural mechanisms of

cognitive training. Such insights could inform

better software design and offer opportunities

to develop training that delivers better transfer

of skills.

Current evidence suggests that, during training,

activity decreases in regions of the brain

concerned with general processes, for example

attentional control, but increases in regions that

perform task-specific functions. Fourteen hours

of training over five weeks was associated with

increased brain activity on a working memory

task and changes in dopamine receptor D1

binding potential in the same areas.45 Further,

studies are beginning to reveal the brain

40 Ball K, et al. (2002) Effects of cognitive training interventions with older adults: a randomized controlled trial. Journal of the American Medical Association 288, 2271–2281.

41 Smith E, et al. (2009). A cognitive training program based on principles of brain plasticity: results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training (IMPACT) Study. Journal of the American Geriatrics Society 57, 594–603.

42 Nouchi R, et al. (2012). Brain training game improves executive functions and processing speed in the elderly: a randomized controlled trial. PLoS ONE, doi:10.1371/journal.pone.0029676

43 Karbach J & Kray J (2009). How useful is executive control training? Age differences in near and far transfer of task-switching training. Developmental Science 12, 978–990.

44 Meltzoff AN, et al. (2009). Foundations for a new science of learning. Science 325, 284–288.45 Olesen PJ, Westerberg H & Klingberg T (2004) Increased prefrontal and parietal activity after training of working memory. Nature

Neuroscience 7(1), 75–79. McNab F, et al. (2009) Changes in cortical dopamine D1 receptor binding associated with cognitive training. Science 323(5915), 800–802.

CHAPTER TITLE

19

areas involved in performing particular tasks.

For example, comparing the brain activity

of children with developmental dyscalculia

(difficulty with understanding and using

numbers) with that seen in children without this

disorder, while playing mathematics games,

can reveal differences in brain activity.46 This

information can in turn inform the evaluation of

the training game in question and aid its further

development. In elderly individuals, fMRI

studies have revealed that computer-based

training can lead to changes in brain structure

in areas known to deteriorate with age.47

These studies use games designed to enhance

cognition, and a variety of longitudinal,

experimental and correlation studies have

shown that playing action video games can

enhance skills in a manner that is transferable

to other contexts.48 These effects are seen

in seasoned gamers, as well as in non-game

players49, and can include the following:

• Performance on visuomotor tasks.

• Switching of visual attention.

• Suppression of visual distraction.

• Inference of an action’s probable outcome.

• Contrast sensitivity (which is a primary

factor limiting sight).

• Affective response (both aggressive and

prosocial behaviour, such as empathy).

Thus, video games might have potential

applications to training for work. Research with

surgeons indicates that those who regularly

play video games pick up certain surgery skills

more quickly and that training on video games

appears to improve performance.50 Studies also

indicate that gaming can provide transferable

skills to army pilots.51 Interdisciplinary

approaches are again key to progress, and

although the neuroscience of video gaming is

still in its infancy, studies are showing promise

in revealing the processes involved in training.

Video games may be good tools for cognitive

training because they are so engaging. In

fact, they can be addictive, triggering similar

neuronal networks to those stimulated in drug

and gambling addicts.52 It is this property

that may make them useful because the

brain’s dopaminergic reward system, which

is stimulated by these games, is implicated

in plasticity and thus in learning. Studies in

neuroscience are beginning to explore the

plasticity involved in the transfer of trained

abilities to real-world tasks, as well as revealing

how different training strategies (e.g. focusing

on individual elements of a task or a whole

task in general) might impact on learning.53,54

For example, games could be designed so that

the reward element is maximised to increase

the likelihood of effective learning. Video

games could also offer promise in cognitive

maintenance. Research in patients with

Alzheimer’s disease indicates that brain training

games might be more effective than traditional

psychostimulation methods in reducing both

cognitive decline and depressive symptoms.55

This interdisciplinary approach has the potential

to lead to better incorporation of video game

processes with learning and training processes.


46 Kucian K, et al. (2011). Mental number line training in children with developmental dyscalculia. Neuroimage 57, 782–795.47 Lovden M, et al. (2010). Experience-dependent plasticity of white-matter microstructure extends into old age.

Neuropsychologia 48, 3878–3883.48 Bavelier D, et al. (2011). Brains on video games. Nature Reviews Neuroscience 12, 763–768.49 Green CS & Bavelier D (2003). Action video game modifies visual selective attention. Nature 423, 534–537.50 Lynch J, Aughwane P & Hammond, TM (2010). Video games and surgical ability: a literature review.

Journal of Surgical Education 67, 184–189.51 Gopher D, Weil M & Bareket T (1994). Transfer of skill from a computer game trainer to flight. Human Factors 36, 387–405.52 Han DH, et al. (2011). Brain activity and desire for internet video game play. Comprehensive Psychiatry 52, 88–95.53 Howard-Jones PA, et al. (2011). Toward a science of learning games. Mind, Brain and Education 5, 33–41.54 Voss MW, et al. (2012). Effects of training strategies implemented in a complex videogame on functional connectivity of attentional networks.

Neuroimage 59, 138–148.55 Fernandez-Calvo B, et al. (2011). Efficacy of cognitive training programs based on new software technologies in patients with Alzheimer-

Type dementia. Psicothema 23, 44–50.

20


Collective enhancement

Although the term ‘enhancement’ traditionally

implies that individuals are the target, we could

also consider it in terms of collective cognition.

Much technology already exists that might

enable this kind of enhancement. Technological

development is offering the potential to create

a truly remarkable range of applications to

enhance human cognition. Such development

sees disciplines converge, particularly device

engineering, computer science, psychology and

neuroscience. Interdisciplinary working will be

key to exploiting this potential.

According to Moore’s law, the number

of transistors that can be placed in a

microprocessor chip doubles approximately

every 18 to 24 months. The degree of memory

density that can be achieved in computing

devices is also doubling at similar rates. This

steady progress makes developments in

engineering very predictable. We can fairly

accurately predict what we will be able to

design and when over the next decade, and

beyond. Consequently, we can look to draw

conclusions about what the implications

might be.

Professor Nigel Shadbolt FREng, Professor

of Artificial Intelligence at the University of

Southampton, told the workshop that, as a

result, we are moving towards a new kind of

augmented intelligence, defined by harnessing

both decision support systems and ambient

computing. To maximise the potential of

augmented intelligence, decision support

systems must be supplemented by a computing

‘fabric’ – the digital environment within which

we are now immersed – that enables us to

harness collective cognition routinely. This kind

of enhancement can support humans to solve

problems individually and collectively that were

previously beyond our capacity.

A good example, so routine now that we do

not necessarily recognise it as enhancement,

is provided by the development of internet

search engines.56 These facilities were

significantly improved by the introduction

of PageRank, an algorithm that assigns

relative importance to web pages based on

connections that users make between them.

This process aims to contextualise information

and optimise its relevance to the user.

The result, apart from the creation of

Google itself, is near instantaneous access

to billions of pages of information across

the Web. This has already transformed the

range of information we can individually and

collectively draw on, and with developments

in next-generation technologies such as the

Semantic Web we can anticipate information

retrieval that is even more customised to

our needs.57

Uniting decision support systems with

ambient computing can also help us to

harness collective intelligence to augment,

for example, problem solving through content

creation. After the earthquake in Haiti, the

rescue efforts required accurate maps of the

capital, Port-au-Prince. However, existing

maps did not provide sufficient detail and

much of the landscape had changed due to

the earthquake. Mappers from across the

world used a combination of fresh satellite

imagery and open-source software using open

standards to generate the missing maps.

This was achieved by providing relief workers

on the ground with the ability to upload their

Global Positioning System (GPS) data along

with annotations they had made about the

routes they had taken that day. The result was

the crowd-sourced creation of a detailed image

of the city layout within 12 days.58 No less

impressive is the collective content generation

that results in resources such as Wikipedia,

56 Cascio, J (2009) Get smarter. The Atlantic Magazine, July/August 2009 http://www.theatlantic.com/magazine/archive/2009/07/get-smarter/7548/

57 Shadbolt N, Berners-Lee T & Hall W (2006) The semantic web revisited. IEEE Intelligent Systems, 21 (3), 96–101.58 United Nations Foundation (2011). Disaster Relief 2.0: the future of information sharing in humanitarian emergencies.

http://www.unfoundation.org/assets/pdf/disaster-relief-20-report.pdf

CHAPTER TITLE

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where the core articles compare favourably

to the very traditional encyclopaedias.59

Collective intelligence of this kind also brings

the advantage of resilience in the face of

attack or misinformation.

Professor Shadbolt reported that the most

successful methods for harnessing collective

intelligence to solve complex problems will rely

on combining conventional computation with

social computation, as outlined in Figure 1.


59 Giles, J (2005) Internet Encyclopedias go head to head. Nature 438, 900–90160 Figure reproduced with the permission of Professor Nigel Shadbolt.61 O’Hara K, et al. (2006). Memories for life: a review of the science and technology. Journal of the Royal Society Interface 3(8), 351–365.62 De Jager D, et al. (2011). A low-power, distributed, pervasive healthcare system for supporting memory. In, 1st ACM MobiHoc Workshop on

Pervasive Wireless Healthcare.63 Hodges S, et al. (2006). SenseCam: a retrospective memory aid. In: 8th International Conference of Ubiquitous Computing.

Of course, such technological developments

can also benefit individuals. For example,

Professor Shadbolt reported that within 15

years, we will have devices small enough

to record an individual’s entire experience

throughout their life as a continuous video

feed, effectively providing a ‘life logging’

function.61 Such a device could be of use

to individuals with memory disorders.62

In clinical trials, patients show better memory

recall and consolidation when presented

with images than when using written logs.63

Mixed or augmented reality will be routine

in the next decade. For example, Google is

developing glasses that they anticipate will

give the user real-time information about

their environment, such as encyclopaedic

knowledge, in a similar way to the current

Social control of healthcare and disease

Social organisation of transport

Social response to emergencies and crime

Climate Modelling

Con

vent

iona

l co

mpu

tatio

n

Social computationdecentralised through society

Problems in this space have:•Small,directimpactlocallywhichismagnifiedwhen

replicated/composed across global society•Huge,potentialimpactgloballybutneedasocialinfrastructure

to harness the local ingenuity and data of humans/sensors.

Compute and data

complexity

Social but centralised systems

AirTrafficControl Co-creatione.g. Wikipedia

Social Networkinge.g. Facebook

Crowdsourcinge.g. Galaxy Zoo

Social complexity

Figure 1: Combining the power of social computation with conventional computation can enable

small, direct, local impacts that could potentially have huge global impacts.60 Compute complexity

describes the computing resources required to perform the analysis.

22


mapping software that uses augmented

reality on mobile devices.64 Immersive

technology that substitutes reality altogether

has been discussed for decades and now has

an established role in training, for example,

jet fighter pilots. As we approach an age

where we can deliver information of

unsurpassed fidelity, substituting reality in

this way could become a lot more efficient

and applicable to other situations. In future,

we will see an evolving information ecosystem,

ubiquitous in our everyday lives and delivered

by mobile and pervasive computing.

This offers unprecedented opportunities to

harness collective cognition, and the social

aspect of computing will be a key element

of driving progress.

Despite the immense growth in technological

development, there is little empirical data on

how cognition is improved with any of these

tools. Participants discussed the fact that

such tools can enter the market without

needing to demonstrate any effects of this

nature, meaning that there is currently little

motivation to collect data on efficacy.

With many of the technologies described, the

process of finding and presenting results is

not entirely transparent to the user. Where

search engines are used, biased results could

be presented to the user, unknown to them if

they do not understand the PageRank process or

the process by which search results are further

filtered. Cognition is enhanced, but there are

questions about the extent to which this can be

considered enhancement if users are remote from

the process. Furthermore, not understanding how

an enhancement works arguably compromises

the use of that enhancement, and the user’s

ability to optimise their use of it.

Impacts on employee motivation

Participants also discussed the use of tools

such as drugs or brain stimulation in relation to

mood enhancement for individuals who are not

currently suffering from a mood disorder. For

example, the use of cognition enhancers or brain

stimulation might be of interest to employees

who find aspects of their work less stimulating.

Many of the enhancements discussed in

this chapter have obvious ethical and social

implications, which are discussed in Chapter 5.

64 https://www.youtube.com/watch?feature=player_embedded&v=9c6W4CCU9M4

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23

Although we consider somatic gene therapy

in this chapter, which is currently being used

for restoration and could be adapted for

enhancement, we deliberately chose to exclude

germ-line gene modification because this is

unlikely to be considered a reasonable approach

for technical and ethical reasons for at least

the next 10 years.65 (It is also prohibited in the

UK and all countries with regulation covering

human fertility and embryo research.)

Sensory enhancement

Cognitive and physical enhancements overlap

when we consider enhancing human senses.

Restoring lost functionality and delaying

degeneration is of particular interest to an

ageing population. In such contexts, it is

difficult to identify the boundary between

restoration and enhancement: for example,

an individual may have abilities that are

3 Physical enhancement

Overview

To date, physical enhancement has been developed primarily with a focus on restoration,

although over the next decade we are likely to see this extend to applications in healthy

individuals. Developments include the following:

• As the average age of the working population rises, individuals are likely to seek to

maintain or restore declines in sensory perception. Better-quality devices like hearing aids will support prolonged auditory abilities, but could also be useful to individuals with

normal hearing in challenging situations, such as in the military. Equally, new techniques to

restore and maintain vision are in development, such as retinal implants, gene transfer

and replacing photoreceptors in the eye.

• Technologies external to the body can support restoration of mobility and limb function, and future applications in healthy individuals might include those whose jobs involve

manual labour. Design of devices like bionic limbs and exoskeletons must overcome

the traditional challenges of user control, energy efficiency and usability if they are to

become more automated and easy-to-use, and thus more accurately mimic or surpass the

functionality of human limbs.

• Tissue engineering and regenerative medicine are offering new opportunities

to replace degenerating tissues. Less complex applications, such as bone and joint

tissues, are entering clinical trials and we are seeing progress in more complex tissues

like tracheas. The most complex cases will produce entire organs, but less involved

techniques that target specific parts of an organ might turn out to be sufficiently

effective. Research to integrate stem cell work with cardiac pumps is another avenue,

which might also be applied to other organs.

• Good nutrition is clearly vital to health and wellbeing, and there may be particular

nutritional approaches that benefit specific aspects of performance, such as stamina,

strength and recovery time. Future applications could be improved by determining the

neuronal basis of overcoming fatigue.

• Cosmetic enhancement could be appealing to some members of an ageing workforce,

in which younger appearance might be believed to have implications for one’s

employment prospects.

65 The only possible exception, currently being considered, is to replace defective mitochondrial DNA, but there are no attempts being made to alter nuclear DNA.

3 PHYSICAL ENHANCEMENT

24


considered normal for someone of their age,

but they may consider the reduced capacity

as a disability. There may also be motives to

enhance non-disabled individuals, for example

to hear or see in challenging situations.

Human hearing

Hearing loss affects individuals increasingly

with age. For the adult population as a whole,

hearing loss of 25 decibels or more affects 16%

of the population. However, progressive decline

in hearing from the age of 20 causes this

figure to rise to 37% in those aged between

61 and 70 years, and further to 60% in those

between 71 and 80.66 Professor Brian Moore

FRS FMedSci, Professor of Auditory Perception

at the University of Cambridge, outlined that,

in the context of work, hearing enhancement

might have the following benefits:

• Allow older people to continue functioning

successfully in the workplace, by effective

restoration or maintenance.

• Enhance hearing for people with normal

perception in noisy or reverberant situations.

Most hearing loss arises in the cochlea.

Individuals experience difficulties in perceiving

low-level sounds and a reduced range of

sound intensities over which sounds are

heard comfortably, accompanied by a reduced

ability to differentiate between the different

frequencies in complex sounds. This results

in an impaired ability to understand speech,

particularly where background noise is present.

Cochlear implants, which have been developed

and refined over the past 40 years, are

surgically implanted to restore some of

the function of the cochlea, for people with

profound or total hearing loss. They often

enable patients to understand speech and

to identify environmental sounds, although

the quality of sounds is not as good as with

natural hearing. Implants consist of an

external microphone, speech processor and

transmitter, connected to an internal receiver

and stimulator. The stimulator converts signals

into electric impulses, which are sent through

an internal cable to an array of electrodes along

the length of the cochlea.

Hearing aids have become increasingly

sophisticated to try to overcome some of the

problems of hearing loss. For example, with

multi-channel compression, sounds are split

into several frequency bands and each one

is amplified to a different extent depending

on the frequency and the input sound level.

This addresses issues with the limited range

of audible and comfortable sound intensities,

but there are limitations in practice. Other

developments look to improve the perception

of speech in background noise. For example,

hearing aids make use of directional

microphones to detect sounds selectively from

the front. Signals can be further enhanced

using digital processing and by using bilaterally

fitted hearing aids (one on each ear) that can

communicate with each other and be remotely

controlled. In the future, remote controls could

be replaced with a sensor that detects brain

signals, but this is many years away.

A novel method of sound delivery for those

with mild to moderate hearing loss is

incorporated in the EarLens system. Sound

is picked up by a microphone in or near the

ear canal, and audio signals and power are

transmitted by a laser to a receiver and

transducer that vibrates the eardrum directly.

This provides high-fidelity amplification over

a wide frequency range. Another benefit

is that the ear canal remains open, meaning

that sounds not produced by the device can

still be heard and the voice of the user sounds

natural. There is also potential for the remote

transmission of signals to this device,

which could be of use in individuals without

hearing impairments.

66 Davis A (1995). Hearing in adults. Whurr. London.

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Hearing enhancement in healthy individuals

could be brought about by other arrangements

of radio systems, in which sounds are

transmitted directly to the ear of the

listener. This reduces background noise and

reverberation and has multiple potential

applications. Immediate applications include

the following: in the classroom, with children

who have attention disorders; with devices

in the home, such as a television; in noisy

factories and other working environments,

or with the military, to allow communication

signals to be received effectively while hearing

protection is being worn.

Further in the future, intensive research is being

conducted on hair cell regeneration. Damage to

the inner and outer hair cells is a common cause

of cochlear impairment. Hair cell regeneration

occurs naturally in birds after damage, providing

an extra impetus for research into how this

might be replicated in humans.

Visual enhancement

In industrialised countries, retinal degeneration

is most commonly caused by age-related

macular degeneration (AMD), which usually

affects individuals over 65 years of age and

accounts for approximately 50% of those

registered blind in the UK. Inherited retinal

degeneration affects younger patients and

can lead to many years spent with disability.

Treatments that use recombinant antibodies

for the treatment of some forms of AMD show

some promise, but are expensive and require

regular injections, for example every month.

Dr Matteo Rizzi, Postdoctoral Fellow at

University College London with Professor Robin

Ali FMedSci, told the workshop that a stable,

viable and one-off solution is therefore sought.

He described three methods by which this

might be achieved in future:

• Retinal implants electronically stimulate

retinal cells when placed either on or

behind the retina. Integration of such

implants presents a significant challenge,

however, given the complexity of the

neuronal network from the retina. In

addition, only very low resolution images

can currently be generated, for example

those that allow identification of a bright

object against a dark background.67

• To date, about 150 different genes

associated with retinal dystrophy

have been identified. Efficient gene supplementation in the retina, using

viral vectors, has been achieved in

mouse models and, more recently, in

patients.68,69,70 In other cases, where

supplementing a specific gene is not

sufficient, the use of light-sensitive

proteins (e.g. channelrhodopsin-2 from

algae) may help to restore light responses

in retinal cells, including those that are

not normally photosensitive.71 However,

several limitations currently exist for

this approach. First, very bright light

is required. Secondly, bypassing the

normal retina circuitry by stimulating

downstream cells will miss important steps

in the processing of visual stimuli. More

generally, the production of large volumes

of clinical-grade viral vectors remains

difficult and expensive, and the changes to

the connectivity of the degenerating retina

present another obstacle.

• Cell replacement represents a promising

solution to restoring function after

photoreceptor degeneration. It has

recently been shown that transplanted rod

photoreceptor precursors do integrate in

the recipient mouse retina, form synaptic

connections with the correct partners and

are able to send a signal to downstream

67 Zrenner E, et al. (2010). Subretinal electronic chips allow blind patients to read letters and combine them to words. Proceedings of the Royal Society B 278, 1489–1497.

68 Smith AJ, et al. (2012). Gene supplementation therapy for recessive forms of inherited retinal dystrophies. Gene Therapy 19(2), 154–161.69 Bainbridge JWB, et al. (2008). Effect of gene therapy on visual function in Leber’s congenital amaurosis. The New England Journal of

Medicine 358, 2231–2239.70 Maguire AM, et al. (2008). Safety and efficacy of gene transfer for Leber’s congenital amaurosis. The New England Journal of Medicine 358,

2240–2248.71 Busskamp V, et al. (2010). Genetic reactivation of cone photoreceptors restores visual responses in retinitis pigmentosa. Science 329,

413–417.


26


cells, including those in the visual

cortex.72,73 It is now essential to identify

the best source of cells for transplantation

and to obtain a sufficiently large amount

of cells from it. Researchers currently use

retinal cells from donor mice, which is not

an option for humans. However, stem cells

have shown promise. An entire synthetic

human retina has been produced in vitro

using embryonic stem cells, and this

technique could provide many appropriate

cells for transplantation.74 In cases such

as AMD, it may be sufficient to replace

a very small percentage of the cone

photoreceptors in the foveola to restore

vision; research with rod photoreceptors

has suggested that this is a realistic goal.

Participants discussed how these kinds of

techniques may in the future aid research into

the extension of the range of human vision to

include additional wavelengths. Examples exist in

animals, such as snakes that can detect infrared

wavelengths, which might provide a source of

research for developing approaches that can

be used in humans. Potential applications could

be envisaged in the military, but also in other

employment, from night watchmen, safety

inspectors, gamekeepers, etc, including the

possibility of enhanced vision at night.

Enhancement of mobility and limb function

Impairments to mobility, coordination and

upper limb function are very common, but

employment rates for such individuals are

well below the national average.75 Two of

the main disabilities associated with low

levels of employment are impairments of

the legs or feet and of the arms or hands.

Several technologies to enhance mobility

are currently on the market, including bionic

limbs and exoskeletons. Although design of

these technologies is continuously improving,

several challenges remain in designing devices

that even come close to mimicking the full

functionality of human limbs. Dr Laurence

Kenney, Reader in Rehabilitation Technologies

at the University of Salford, highlighted three

key challenges.

1. Control

Issues with the control of upper limb

prostheses illustrate some of the major

challenges common to some other assistive

devices,76 including the following:

• The signal that controls powered prostheses

is the electrical activity measured via

socket-located electrodes overlying one

or two residual muscles. The transduced

signal is influenced by external factors, such

as sweat and loads on the socket-located

electrodes, which introduce uncertainty into

the control system.

• The motor that opens the hand is switched

on once the rectified and smoothed signal

exceeds a threshold. Such an approach to

signal processing is slow, leading to a lag

between command and response.

• The absence of feedback on the state of

the hand means that the user must rely on

visual feedback, a much slower feedback

loop than spinal reflexes.

• Most hands operate with one, or at most

two, simultaneously controlled degrees of

freedom, owing to the limited number of

control sites and difficulty with controlling

more independent degrees of freedom.

This greatly limits their dexterity.

These limitations mean that current devices

offer limited enhancement of functionality,

which is reflected in low levels of everyday use

and high rejection rates.77

72 MacLaren RE, et al. (2006). Retinal repair by transplantation of photoreceptor precursors. Nature 444, 203–207.73 Pearson RA, et al. (2012). Restoration of vision after transplantation of photoreceptors. Nature 485, 99–103.74 Eiraku M, et al. (2011). Self-organizing optic-cup morphogenesis in three-dimensional culture. Nature 472, 51–56.75 Office for National Statistics (2011). People with disabilities in the labour market – 2011. http://www.ons.gov.uk/ons/dcp171776_242963.pdf76 Bongers RM, et al. (2012). Hierarchical levels of construction of movements applied to upper-limb prosthetics. Journal of Prosthetics and

Orthotics 24, 67–76.77 Biddis E & Chau T (2007). Upper-limb prosthetics: critical factors in device abandonment. American Journal of Physical Medicine and

Rehabilitation 86, 977–987.

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New technologies might in future address

these issues. The slow nature of control

algorithms may be improved by using different

physiological signals such as real-time

ultrasound,78 brain–computer interfaces79 and,

for above-elbow amputees, targeted muscle

re-innervation.80 However, with the exception

of targeted muscle re-innervation, these

technologies remain some way from clinical

exploitation. Artificial feedback loops are

being explored to reduce the need for visual

feedback. These include systems already

in clinical use for controlling grip strength

based on slip detectors, and the rapidly

emerging area of biofeedback to the residual

limb.81 Finally, more dextrous hands are

already in use in anticipation of better control

approaches emerging.82

2. Energy efficiency

A good example here comes from studying

the gait of lower-limb amputees. Gait consists

of a stance phase while the foot is in contact

with the ground, and the swing phase while

the foot is swinging forward. The energy

efficiency of gait is influenced by the positive

mechanical work at the ankle in the final part

of the stance phase (i.e. at push off). Standard

prosthetic feet are passive viscoelastic devices

that store energy early in stance, and release

it later in stance. However, in contrast to the

human ankle, when walking with a passive

prosthetic foot there is no positive work

produced at the ankle and no control over how

the stored energy is released. The combined

effects contribute to the low energy efficiency

of amputee gait; about 20% lower in below-

knee amputees and worse in above-knee

amputees.83 Research is looking to address this

problem using advanced control techniques.

For example, the use of springs and a clutch

mechanism can facilitate more effective storage

of energy, which can then be retained until near

the end of the stance, when it can be used for

push off.84

3. Usability

Difficulty in using assistive devices has limited

their uptake. A good example is provided by

the use of functional electrical stimulation for

foot drop, a condition that is common after

stroke and is characterised by the foot failing

to lift properly during swing, leading to slow,

unsteady and tiring gait. The use of small

electrical pulses to induce a muscle contraction

can help to correct foot drop. Standard devices

use two electrodes, the placement of which is

critical to good performance. However, it can

be challenging for individuals recovering from

stroke to remember the correct position of the

electrodes and poor placement can lead to the

foot turning sideways, or even downwards.

Systems to overcome this issue are currently

being developed with patients, in which the

critical electrode is divided into an array of

small electrodes and software is used to locate

the best spot for stimulation.85

To overcome these challenges and optimise the

development of these technologies over the

next decade, interdisciplinary approaches and

co-development with users will be increasingly

valuable. Devices need to become increasingly

automated and easy to use.

78 Zheng YP, Chan et al. (2006). Sonomyography: monitoring morphological changes of forearm muscles in actions with the feasibility for the control of powered prosthesis. Medical Engineering and Physics 28(5), 405–415.

79 Kreilinger A, Neuper C & Müller-Putz GR (2012). Error potential detection during continuous movement of an artificial arm controlled by brain-computer interface. Medical and Biological Engineering and Computing 50(3), 223–230.

80 Kuiken TA, et al. (2009). Targeted muscle reinnervation for real-time myoelectric control of multifunction artificial arms. Journal of the American Medical Association 301(6), 619–628.

81 Saunders I & Vijayakumar S (2011). The role of feed-forward and feedback processes for closed-loop prosthesis control. Journal of NeuroEngineering and Rehabilitation. 8, 60.

82 For examples, see http://www.touchbionics.com/ and http://bebionic.com/.83 Waters RL & Mulroy S (1999). The energy expenditure of normal and pathologic gait. Gait Posture 9(3), 207–231.84 Collins SH & Kuo AD (2010). Recycling energy to restore impaired ankle function during human walking. PLoS ONE 5, e9307.85 Reeves M, et al. (2010). Shefstim: a clinical trial of self-tuning array stimulation for foot-drop. In Kenney LPJ and Cooper G (eds) (2010).

Proceedings of the 1st Annual Conference of the UK and Republic of Ireland Chapter of the International Functional Electrical Stimulation Society. University of Salford, Salford, UK.


28


Physiology and tissue engineering

Research into human physiology and tissue

engineering provides numerous opportunities

for physical enhancement. Professor Molly

Stevens, Professor of Biomedical Materials

and Regenerative Medicine at Imperial College

London, told the workshop that every organ

and tissue in the body is now a target for

research. Tissue engineering combines cellular

biology, materials science and engineering to

generate new tissues. Regenerative medicine

is an application of tissue engineering whose

success depends on careful consideration of

the structure and function of the cells, and the

tissue or organ, to be repaired. Many factors

can influence success, including the tissue type,

the nature of the disease, the size and scale

of the tissue defect and the age of the patient.

Although this kind of research is not new,

the goals of these endeavours have changed

in recent years. The ambitious early aims of

reconstructing entire organs have largely given

way to smaller, more attainable goals. For

example, rather than trying to replace an entire

heart, clinical advances in cardiac repair now

focus on targeting coronary arteries, valves and

the myocardium muscle individually.

The use of stem cells to regenerate tissue is

an area of significant research activity. There

are currently almost 3000 clinical trials globally

that use stem cells for numerous applications.86

In terms of more complex tissue engineering,

potential developments over the next decade

are tissue-dependent and, in part, determined

by the types of biomaterial available. For

example, there are multiple options for work on

bone and cartilage, but fewer in more complex

tissues such as nerves.

As a result, one of the most advanced

applications of tissue engineering is in joint

replacement, where the use of stem cells and

bioactive scaffolds can generate tissues that

are more likely to be successfully integrated

into the recipient. Professor Stevens described

‘in vivo bioreactor’ for bone regeneration which

harnesses a patient’s own cellular processes

to enable new bone tissue to be generated

underneath the surface of an existing bone—an

area rich in pluripotent cells. This technique

provides new bone in sufficient quantities to be

transferred elsewhere within the same patient.

Because the bone is generated by the body

itself, it is biomechanically identical to native

bone.87 These kinds of techniques are also

being explored for application to other vital

organs, such as the liver or pancreas.

Many tissue engineering approaches currently

require the use of three-dimensional scaffolds in

place of an extracellular matrix. Cells are seeded

into the scaffolds and new tissue develops.88

New ‘sheet-based’ tissue engineering techniques

are now in development, which avoid the use of

a scaffold, and within the next 10 years we could

see ‘off-the-shelf’ engineered tissues that are

entirely specific to the patient. Blood vessels are

a likely application here.89

Given the prevalence and likely future burden of

heart disease, the heart is a particular focus for

research. For example, over 20 million individuals

worldwide live with congestive heart failure.90

Participants noted that where the future of work

is concerned, cardiovascular health is important

for several reasons, including the importance

of cardiorespiratory fitness to both physical and

mental wellbeing, and because fitness is a source

of stamina, endurance and productivity.

Solutions to heart disease might see patients’

cells seeded into a matrix that is placed over

the myocardium muscle to restore function,

for example after heart attack or in engineering

86 For examples, see http://www.eurostemcell.org87 Stevens MM, et al. (2005). In vivo engineering of organs: the bone bioreactor. Proceedings of the National Academy of Sciences of the USA

102, 11450–11455.88 Langer R & Vacanti JP (1993). Tissue engineering. Science 260, 920–926.89 L’Heureux N, McAllister TN & de la Fuente LM (2007). Tissue-Engineered Blood Vessel for Adult Arterial Revascularization. The New England

Journal of Medicine 357, 1451–1453.90 Redfield MM (2009). Heart failure:an epidemic of uncertain proportions. The New England Journal of Medicine 347(18), 1442–1444.

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replacement valves from a patient’s own cells

(rather than using mechanical valves or those

of animal origin), and these may soon enter

clinical trials. Further in the future, techniques

might enable development of entirely

engineered hearts, in which cells are removed

from a heart until only the matrix remains,

which is then repopulated with patient-specific

cells. Research is also exploring how whole

organs might in future be ‘printed’ using cells

and polymers. However, the complexity of the

task, for example to arrange blood vessels

correctly in a new organ, means we are

some years away from clinical application. As

progress is made in work on specific parts of

tissues and organs, this kind of more complex

option may not be necessary.

In severe cases of organ failure, transplantation

is used. This, however, is expensive, requires the

use of immunosuppressants and is accompanied

by some ethical concerns. Options for heart

transplant patients have been improved by

artificial heart pumps, or ventricular assist

devices, particularly to bridge the gap to

transplantation. In fact, heart pumps are now

performing almost as well as transplants in terms

of survival rates.91 Research is also exploring how

heart pumps might be interrelated with stem-

cell work to improve the effectiveness of heart

transplants further. Professor Stephen Westaby,

Cardiac Surgeon at John Radcliffe Hospital in

Oxford, told the workshop that this kind of

artificial heart has already been used in trials

and could begin to replace transplantation within

the next decade.92 However, such solutions are

currently very expensive, up to £100,000, and

more inexpensive designs will be needed if they

are to become accessible to healthcare systems.

Developments are also needed to optimise the

power supply to these devices, which require

a permanent power line from outside the

body into the internal organ. Such a set-up

brings vulnerability to infection. Techniques

to fix the power line in place, using a pedestal

planted in the skull, could help to reduce this

issue. Professor Westaby also reported that

artificial lungs are in development, but that

these present further challenges as recipients

must carry gas, as well as a power supply.93

Implantable kidneys and liver could also be

on the horizon.

Nutrition and performance enhancement

A healthy lifestyle, including good diet and

nutrition, is clearly fundamental to maintaining

health and wellbeing. Specific nutritional

approaches might be used to improve particular

aspects of performance, however. Participants

discussed how these are often most useful

to individuals working at the limits of human

capacity. Due to the illegality of performance-

enhancing drugs and the capacity to exhaust

options to improve performance through

training, sport is one of the first areas to

embrace new developments in nutritional

interventions that might provide users with a

small but significant competitive advantage.

Professor Ron Maughan, Professor of Sport and

Exercise Nutrition at Loughborough University,

told the workshop that athletes are often willing

to try new approaches even if some aspects of

efficacy and safety are unknown. It may be that

these approaches have applications in specific

cases in the wider population as well.

Long-term nutritional approaches can facilitate

improved performance, for example enabling

harder training without chronic fatigue, injury

and impaired immune function. Training

regimens can be designed to enable muscle

remodelling and to alter gene expression, and

the right nutrient environment can enhance

the functional consequences of a training

91 Westaby S, et al. (2010). Destination therapy with a rotary blood pump and novel power delivery. European Journal of Cardio-Thoracic Surgery 37(2), 350–356.

92 Anastasiadis K, et al. (2011). Hybrid approach of ventricular assist device and autologous bone marrow stem cells implantation in end-stage ischemic heart failure enhances myocardial reperfusion. Journal of Translational Medicine 19, 9–12.

93 Wu ZJ, et al. (2012). Thirty-day in vivo performance of a wearable artificial pump-lung for ambulatory respiratory support. The Annals of Thoracic Surgery 93, 274–281.


30


programme. For example, intake of essential

amino acids (especially leucine, which can be

in the form of whole proteins from food rather

than as supplements) after exercise promotes

muscle protein synthesis and net protein

balance, and enhances muscle adaptation.94

Such approaches could be applied to elderly

or unwell individuals with disuse atrophy,

i.e. where muscle mass decreases and the

muscle weakens owing to age or lack of use.

Muscle has been shown to be responsive to

training and nutritional interventions even into

extreme old age.95 A recent study showed

that maintaining amino-acid availability by

intragastric infusion of protein during the

night increased net protein synthesis in elderly

men.96 Some nutritional supplements also

show promise in supporting muscle growth, fat

loss and physical performance. Dietary nitrate

(found in high concentrations in beetroot

and some other vegetables), for example,

can reduce the oxygen cost of exercise by

3–4%, apparently by improving mitochondrial

efficiency.97 Such an effect could have

significant benefits for endurance athletes, but

could also benefit individuals with pulmonary

or cardiovascular impairments that limit

oxygen delivery to peripheral tissues. There is

emerging evidence also for a role for dietary

nitrate in blood pressure reduction and other

cardiovascular and metabolic benefits.98

Nutrition may also be used acutely to provide

specific performance effects. Caffeine is an

obvious example here, which can enhance

exercise performance by actions on adenosine

receptors in the central nervous system.

Carbohydrate intake can enhance performance

by slowing the development of fatigue during

activity lasting more than one hour. Although

there is a physiological explanation for this

effect (the sparing of endogenous glycogen

stores), there is also a psychological aspect,

in terms of the perception of effort required,

which can often be the ultimate limit to

performance. For example, in studies where

a carbohydrate solution is swilled around the

mouth and not swallowed, some improvement

in performance is seen, though not as much

as if it is swallowed.99 It is not yet clear

whether the brain adapts after multiple

experiences. The brain is increasingly a target

for studies into overcoming fatigue, and brain

imaging and pharmacological interventions

are now being used to explore the neurological

and neurochemical bases for these effects.

This could lead to novel approaches to

performance enhancement, both for athletes

and for other populations.

Cosmetic enhancement

Although cosmetic enhancement was not a

central focus of the workshop, participants

highlighted that it is one of the most well-

established types of physical enhancement,

which has applications that are both

restorative or that take individuals ‘beyond

the norm’. Techniques that enable cosmetic

enhancement are constantly evolving, with

new ones being developed and the range of

different enhancements possible widening. It

will become increasingly difficult to distinguish

cosmetic enhancement from more traditional

beauty treatments, for example as beauty

products and treatments become increasingly

sophisticated. Cosmetic enhancement could

have particular relevance to the context of

work as the appearance of being younger

may have implications for one’s employment

prospects, which might be particularly

94 van Loon LJC & Gibala MJ (2012). Dietary protein to support muscle hypertrophy. In Maughan RJ and Burke LM, eds. (2012) Sports nutrition: more than just calories – triggers for adaptation. Nestlé Nutrition Institute Workshop Series, 69, pp 79–95. Karger, Basel.

95 Breen L & Phillips SM (2011). Skeletal muscle protein metabolism in the elderly: Interventions to counteract the ‘anabolic resistance’ of ageing. Nutrition and Metabolism 8, 68.

96 Groen BB, et al. (2012). Intragastric protein administration stimulates overnight muscle protein synthesis in elderly men. American Journal of Physiology, Endocrinology and Metabolism 302(1), E52–E60.

97 Larsen FJ, et al. (2011). Dietary inorganic nitrate improves mitochondrial efficiency in humans. Cell Metabolism 13(2), 149–159.98 Lundberg JO, et al. (2011). Roles of dietary inorganic nitrate in cardiovascular health and disease. Cardiovascular Research 89(3), 525–532.99 Carter JM, Jeukendrup AE & Jones DA (2004). The effect of carbohydrate mouth rinse on 1-h cycle time trial performance. Medicine and

Science in Sports and Exercise 36(12), 2107–2111.

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pertinent within an ageing society. However,

it is also possible that as an increasing

proportion of the workforce is of older age,

any real or perceived need to exhibit a

youthful appearance for reasons related to

work will decline. The relevance of cosmetic

enhancement will inevitably vary with different

types of job.

The use of pharmaceuticals is also relevant

here. The use of anabolic steroids for

the purposes of bodybuilding and image

enhancement is rising among the general public

and young people in particular.100 In 2010,

the Advisory Council on the Misuse of Drugs

(ACMD) expressed concerns about the use of

anabolic steroids, which are currently classified

as class C drugs by the UK Misuse of Drugs

Act. As well as enabling image enhancement,

these drugs can also improve strength, which

could be an attractive outcome to individuals

(or employers) working, for example, in manual

labour industries. Some of the harms of these

drugs are discussed in Chapter 5.

100 Advisory Council on the Misuse of Drugs (2010). Consideration of the anabolic steroids. http://webarchive.nationalarchives.gov.uk/+ http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/acmd1/anabolic-steroids-report/anabolic-steroids?view=Binary


32


CHAPTER TITLE

33

There are also questions to be addressed as

to whether the development of enhancement

technologies could represent a good target

for UK investment and whether the UK

should seize on the opportunity to create a

new industry, or enhance existing domestic

industries and their workforces to compete

successfully in a shifting global market.

The discussion at the workshop focused less on

how enhancement use among employees might

benefit the competitiveness of an organisation,

which is explored further in Chapter 5.

Technologies can only reach the market if they

have sufficient financial backing. Participants

discussed how several determinants influence

the commercialisation opportunities of a novel

technology, such as whether it represents

unique intellectual property and the size of

the market, but the key issues relate to the

market risk (technology adoption) and potential

uptake, and the risk of the technology failing

to deliver its claimed cost–benefit advantages.

When considering enhancements in the context

of work, technological development must

consider the end users – both employers and

employees – and the views of particular interest

groups such as trade unions.

The enhancement technologies discussed

probably represent multiple markets, rather

than a single ‘enhancement’ market. Dr Andrew

Elder, Partner at venture capital investor

Albion Ventures, reminded the workshop that

investment decisions, at least for private

investors, are based not only on commercial

opportunities (market prospects), but on the

investment prospects, i.e. investors must

envisage returns within a set period. Dr Elder

noted that some enhancement technologies

could represent huge commercial opportunities,

in both healthcare and non-healthcare markets.

In healthcare markets, technologies are often

designed to correct some kind of ‘deficit’,

as is the case with several of the physical

enhancements described. The potential size or

attractiveness of healthcare markets is often

limited by several constraints, including a

high degree of regulation and a lengthy route

to market. The existence of such constraints

varies, however. Traditionally, medical devices

are subject to less scrutiny than drugs,

although recent cases in which approved

devices led to significant side effects will serve

to increase the regulatory requirements on

new devices. The INFUSE® bone graft, for

example, was approved by the US Food and

Drug Administration for lower back procedures,

but the high concentration of growth factor

implanted in this device led to side effects

including cancer and male sterility.101

4 Commercialisation opportunities and challenges

Overview

Whether or not enhancement technologies represent a viable investment opportunity will

clearly determine the level of development seen. This market might represent a profitable

new industry but defining the timing of market realisation is challenging in view of technical,

regulatory and collaborative challenges. Non-invasive technologies are likely to attract more

investment, given the lower level of regulation and because provision is less likely to rely on

finite state resources. Such technologies, especially if they exist online, could have enormous

reach. Markets are global as demonstrated by the advent of social media; sometimes beyond

the regulation and control of governments across the world. Balance needs to be struck

between promoting and over-claiming the benefits of new technologies.

101 The June 2011 issue of The Spine Journal featured a collection of articles exploring the active ingredient in the bone graft.

4 COMMERCIALISATION OPPORTUNITIES AND CHALLENGES

34


We see a different investment dynamic with the

non-healthcare market, which might represent

big commercial and investment opportunities

as it is not subject to the same constraints.

Some of the non-pharmacological cognitive

enhancements could be attractive to investors

here. Enhancement tools that exist online, for

example, bring enormous potential reach for

lower relative investment. Cognitive training

games could provide a high margin as they

can be widely distributed at low cost and bring

minimal downsides such as side effects.

Whether an enhancement can create a market

depends on its target indication, for example in

terms of the level of enhancement produced,

the degree of unmet need and the severity

of the underlying deficit being addressed.

Investment decisions are founded on

understanding market needs and gaps for the

creation of new market categories; it is vital to

assess whether the nature of the enhancement

is to push or be pulled into the market.

The pricing structure of the market also

has a huge impact on market opportunity:

pricing and who pays are key determinants

of commercialisation opportunities. A large

component of costs in the healthcare market

is covered by healthcare systems, which

has huge implications for the commercial

viability of an opportunity. Hearing aids have

been commercially attractive because they

have a high margin and can be produced in

high volumes, with relatively low regulatory

hurdles; there is a very identifiable end-user,

there are large numbers of end-users (with

an increasingly aged population), the benefits

are demonstrable through the extended

‘independence’ of the end-user and they are

accessible to healthcare systems in cost terms.

Exoskeletons; potentially used by manual

workers as well as the elderly, on the other

hand, must be adapted to the user, making

production difficult to scale-up. They also

require a much greater service element to

support integration and training. As a result,

without reductions in costs, high technology

exoskeletons are currently unlikely to be

widely affordable to employers and healthcare

systems in the foreseeable future, though

they may attract self-pay customers who

are better positioned to assess their degree

of enhancement and so the price they are

prepared to pay for it.

Mr Phil Newman, Chief Executive Officer of

PERGALI, who previously led commercial

development and marketing at Touch Bionics,

a provider of prosthetic technologies, told the

workshop that the only way to assess and

respond to the opportunities accurately, as

well as the challenges, is to bring these factors

together to create a market map of potential

physical and cognitive enhancements; and

identify each one’s proximity to realisation.

Although this represents considerable work,

it would aid the identification of commercial

opportunities and help nearer-term prospects

to appear more tangible to the audience (both

consumer and investor). Technologies would

be ranked and rated based on a selection of

factors, such as the following:

• Time to market (proximity of available

technology).

• Regulatory considerations.

• Cost of development and therefore

market price.

• Target users and application of

the technology.

• Return on investment and health economics.

Such a map can help marketeers to make more

informed decisions about new technologies

and can drive investment decisions, which

will also be supported by developing a good

understanding of potential markets, including

what users might want from technologies

and how technologies might be integrated

into their future lives. Mr Paul Mason, Head

of Development at the Technology Strategy

Board, stressed that markets are global

and thus defined by the actions of multiple

governments. Any market map should address

the international market. The foundation

for investment decisions, as well as those

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35

related to use, regulation and accessibility

of technologies, must be an understanding

of global developments. Although this will

be an important component of informing UK

competitiveness, it remains important to work

with other countries to inform this awareness.

Professor Nikolas Rose, Professor of Sociology

and Head of the Department of Social Science,

Health & Medicine at King’s College London,

cautioned that ‘over claiming’ the benefits of

technologies can impact on the future success

of novel developments. Disciplines such as

genomics, neuroscience and synthetic biology

provide many interesting insights and may

bring benefits to users, but there is a need

to distinguish the market hype from reality.

Professor Rose told the workshop that ‘over

claim’ characterises emerging technologies

and is linked to a ‘political economy of hope’,

in which the hopes of patients, politicians,

scientists and commercial enterprises sit

alongside warnings from the military that

we may see a new arms race in enhancement

technologies, to drive the discourse of

enhancement. Professor Rose cautioned

that this language, including the term

‘enhancement’ itself, is embedded in this

pervasive culture of ‘over claim’. Caution and

scepticism support robust science and facilitate

more productive discussion. If overestimated

promises do not come to fruition, there are

negative implications for industry, science

and users. Another participant stressed that

although scepticism can be helpful, being

over-cautious can slow progress and delay

access to technologies that could help

numerous individuals.

4 COMMERCIALISATION OPPORTUNITIES AND CHALLENGES

36


CHAPTER TITLE

37

5 Potential implications for the future of work

Although there has been extensive discussion

of the general implications of human

enhancement, as far as we are aware there

has been little debate about how human

enhancement technologies might impact on

the future of work. This chapter looks at how

enhancement might be used at work, considers

the data required to enable a full understanding

and explores how issues raised in general

discussion about enhancement might be of

particular relevance to this context and whether

any unique issues arise. Any such issues could

influence the desirability, acceptability and

future use of enhancements at work.

Overview

Enhancements could have many applications to work in the future, which might benefit both

employees and employers, but the potential implications may well be complex, unpredictable or

divisive.

• Enhancement could benefit employee efficiency and even work–life balance, but there is a

risk that it will be seen as a solution to increasingly challenging working conditions, which

could have implications for employee wellbeing.

• Work to identify the potential harms of new technologies should be pursued to support

decisions by users – both employees and employers – but data are currently lacking and

difficult to collect.

• The usefulness of technologies will vary with context. Enhancements will benefit

different occupations in different ways and, importantly, every user will exist in unique

circumstances. To benefit fully from enhancement technologies, integration must therefore

focus on the individual.

• There are few data on the current and potential use of enhancements or on how publics

view the use of enhancements at work. Ongoing dialogue will be vital in developing an

understanding in these areas.

• Particularly complex questions are raised by the use of enhancements in occupations where

work is related to responsibilities to others, for example surgeons performing lengthy

operations or passenger coach drivers.

• The use of enhancements could widen access to certain occupations. However, access to

the enhancements themselves may be restricted by cost, thus raising questions over who

funds provision.

• If technologies enter mainstream use at work, there is a risk that individuals will feel

coerced into using them, with consequences for individual freedom.

• The use of restorative technologies could enable disabled individuals to enter, or return to,

work and might lead to a blurring of the boundary between those considered disabled and

those not. This could have significant implications for individuals who do not wish to make

use of such technologies and for any decisions over funding that are related to whether a

technology is defined as enhancement or restoration.

5 POTENTIAL IMPLICATIONS FOR THE FUTURE OF WORK

38


Enhancement and work

Enhancements will not simply be applied to

all individuals and all organisations; their

expense and the likelihood of diverse effects

in different individuals are just two possible

reasons for differential uptake. To use

enhancements most effectively (or any other

technology or training method), any factors

limiting performance must be identified and

targeted. The use of enhancements is thus

likely to be task-specific and designed to

meet the user’s needs. In practice, of course,

the use of enhancements will not be as

simple as identifying the limiting factor and

applying a particular technology to improve

it, and participants discussed how the use of

technology alone can only ever form part of

an approach. Many other factors, including

opportunity and commitment to the cause,

will influence the outcome of an individual’s

efforts. However, enhancement could play a

role in work, by the following means:

• Influencing an individual’s ability to learn

the tasks required for their work.

• Influencing their ability to perform

those tasks.

• Influencing their ability to enter a profession.

• Influencing their level of motivation when

performing tasks.

• Reducing work-related damage or stress –

physical and cognitive.

• Supporting individuals to return to work

after illness.

Thus enhancements will likely impact on

different occupations in different ways. Where

work is strongly based on competition, such as

in the case of athletes, there will be a strong

motivation to enhance. This is demonstrated

by, for example, this group’s position at the

forefront of exploring nutritional supplements

as enhancements. Individuals involved in work

that is high risk or high stress may benefit

from enhancements if they improve safety and

reduce potential harms. This might include

the desire to diminish certain experiences or

abilities, for example the effects of jetlag or

of the neurological condition synaesthesia,

in which two or more of the human senses

are involuntarily joined together. However,

as discussed in relation to using technologies

in practice below, this is accompanied by the

risk that enhancements might be seen as a

substitute for a healthy working environment

and conditions. Similarly, shift workers could

benefit from enhancements that improve their

awareness or resilience to cope with challenging

working patterns, which can be associated

with mental or physical problems. Equally,

occupations that require particular patterns

of focus could benefit from enhancements

that facilitate achieving such patterns. For

example, surgeons may need to be able to

concentrate for extended periods, whereas

other jobs such as air traffic control can require

very rapid reactions during periods of relative

uniformity.102 As an extrapolation to this, it

is possible that in these high-responsibility

occupations enhancement could be seen as

a moral obligation, or even demanded by the

public. Recent examples of traffic accidents

involving passenger coaches draw attention

to the drivers of these vehicles as another

potential target for such demands. Situations

like this will require careful consideration.

Enhancing individuals could also be of

benefit to collectives. Organisations may

see improvements in, for example, employee

efficiency and coordination, and thus also

in productivity. There could be economic

benefits to organisations and society more

widely as a result of a minor but widespread

improvement in cognition. In addition, as

discussed in Chapter 2, technology could

enable us to use collective intelligence to

solve problems that were beyond the

capabilities of previous collectives.

102 Morein-Zamir S & Sahakian BJ (2011). Pharmaceutical cognitive enhancement. In Illes J & Sahakian BJ, eds. (2011) Oxford Handbook of Neuroethics. Oxford University Press, Oxford UK.

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Using technologies in practice

The nature of work, of work-associated illnesses

and of the composition of the workforce is likely

to change over the next decade and beyond

(see Box 2). There could be real opportunities

for enhancement technologies to be used to

the benefit of employees, attractive both to

them and their employers. Enhancers might

support individuals in adapting to the changing

work environment, for example by supporting

older people to continue to work. They could

also enable more efficient working and thus

could facilitate an improvement in work–life

balance and employee wellbeing. In addition,

businesses are likely to experience rising

pressure to gain a competitive edge, given

the ongoing global economic situation and

continued rise in the globalisation of work—

this could encourage an ‘enhancement race’.

Using enhancements will need to represent a

financially viable option; for example, the cost

of any increase in productivity should be less

than simply employing extra staff. Also relevant

here is the fact that it may be cheaper to

employ able-bodied people rather than to buy

complex technologies to enhance the less able.

For technologies to support individuals

successfully in continuing to work, there must

be a realistic assessment of genuine needs and

of what technologies can deliver. The user’s

expectations must coincide with the potential

and actual outcomes; incompatibility between

the two can result in discontinuance of use and

disenchantment. Not only this, but employers

must understand where there are discrepancies

between needs and outcomes if they are to

place realistic expectations on their employees

and support those employees in making the

best use of technologies. In practice, it will be

important to consider what the most appropriate

intervention is for any individual, in terms of the

objectives of enhancement. This will depend on

the nature of the work in question.

Participants noted that, in the next few

decades, we are unlikely to see enhancement

technologies that provide any more than a

relatively low degree of improvement in a

particular capacity for a finite amount of time.

The complexity of the brain, for example,

and the sociotechnical system within which

it functions, means that we cannot currently

know for sure that when we try to modify

one particular faculty, all others will remain

unchanged. Studies into cognitive enhancement

do not normally also investigate whether

there is a cost to enhancement. If a decline in

other functions results, it will be important to

understand how and to what degree this might

be an issue. This kind of information will be

important to individuals, who will have unique

objectives for their use of enhancements and

will draw different conclusions about risk–

benefit ratios. One participant highlighted

the perspective from evolutionary biology;

evolution has seen the optimisation of

processes through biological trade-offs and

we must understand this to identify where

we might feasibly improve capabilities.

Dr Pamela Gallagher, Senior Lecturer in

Psychology at Dublin City University, stressed

that we must understand an individual’s

psychosocial perspective; that is the personal,

social, emotional, cultural and environmental

circumstances that will enable users to benefit

most from a technology. An enhancement

technology, irrespective of whether it is placed

in the user’s environment, on their person

or in their body, is effectively an interface

between that individual and the life they wish

to lead. It is therefore how people react to

technology, rather than the technology itself,

that determines how enhancing it will be.

Box 4 outlines the importance of a user-

centred approach and of the role that

reinforcement and feedback play in an

individual accepting a technology.


40


103 Scherer MJ (2005). Living in the state of stuck: how technology impacts the lives of people with disabilities (4th ed). Brookline Books, Cambridge MA.

Box 4 Aspects of a psychosocial perspective

A user-centred approach

Enhancement technologies, even those that represent collective enhancement, are ultimately

used by individuals. Integration therefore depends on human behaviour. Psychological and

social aspects must be combined to promote a user-centred approach to the use of novel

technologies. Successful uptake may be improved by drawing on, for example, models of

human behaviour, motivation theories, self regulatory theory and goal theory. Efforts to

generate a model for matching person with technology take into account not only the salient

characteristics of a technology, but also the characteristics of the environment and the

circumstances in which it will be used, including relevant features of a user’s personality,

temperament and preferences.103 Such models can help us to understand how employees and

employers, as end users, might make best use of technologies. For example, an individual

with a prosthesis could view themselves in relation to that device in several ways. For some,

the prosthesis may represent their inability to perform certain activities, emphasise their lack

of completeness or be a focus for perceived stigma associated with their physical condition.

Yet, for others, a prosthetic device may represent their enablement or their ability to harness

technology and to participate fully in society. Realising the potential of a new enhancement

technology may be restricted by our ability to integrate it into our lives, and how people ‘read’

the technology they are using is potentially one of the most powerful psychosocial factors in its

integration. Every user has unique circumstances and the intended use must match the user,

even for technologies that are likely to be widely used.

It takes time to adapt to using a new technology. Positive and effective interventions may

require significant effort, time and labour on the part of the user, which may result in a period

of time during which they are less, rather than more, efficient and productive. In some cases,

the desired change will never arrive, which, given that the technologies are meant to provide

improvement, could be perceived as a ‘failure’ of the individual. The user must therefore also

be central to evaluating the outcome of a technology, which must recognise that there is a limit

to what can be achieved and avoid preconceived ideas about what might be important to the

user. Benchmarks of success should be flexible, achievable and focused on the user. Success

is defined not only in terms of realising the primary objective of a technology, but on the

psychological, spiritual, emotional and social components that contribute to the person’s quality

of life, which will again vary between individuals.

Reinforcement and acceptance of technology

Feedback can play a critical role in reinforcing the usefulness of technology and is thus

fundamental to its successful and continued use. This feedback could come in several forms:

from as simple as enjoyment and interest, which in turn may act as an internal motivation

for continued use, to the knowledge that one has control over the outcome and function of

the technology. Feedback can also inform improved use of a technology, through monitoring

progress and comparing current achievements to the ultimate goal. Setting achievable goals

and sub-goals is crucial, and sometimes regaining functionality will be a slow and arduous

process, meaning that immediate reinforcement is not possible. Such cases must be recognised

so that interim motivations and rewards can be identified.

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41

Generally participants felt that if we use

technologies to address any of these issues,

we must tread carefully. Enabling individuals

to work more comfortably is desirable.

However, as highlighted by Professor Rose,

it is very different from using technology to

try to transform workers, whether young or

old, to fit into an increasingly demanding

and ‘intolerable’ work regime. For example,

individuals might be able to cope with the

increasing globalisation of work by making use

of modafinil to overcome jetlag. However, other

technologies will enable greater use of video

conferencing, for example, which could enable

working conditions to be changed, rather than

the employee. Making work more technological

in this way emphasises the position of humans

as ‘components’ of a system, and careful

consideration is needed as to whether this is

acceptable, and whether instead we should be

looking to ‘humanise’ work. Good job design

aims to provide employees with an appropriate

range of activities and interactions in their

work, in which stress and intellectual demands

are appropriately balanced and employees are

granted adequate levels of control over their

work. Such job design aims to provide not only

job satisfaction, but circumstances in which

employees are sufficiently alert so that they

can respond when necessary. For example,

jobs that require fast responses, such as air

traffic controllers, include plenty of breaks to

maintain their concentration. Concentration

aids may allow them to work better for longer,

but a system that relies on enhancement

technologies may result in jobs that are

generally less satisfying and, further, could

introduce additional failure mechanisms, where

employees no longer respond to situations

as required. Moreover, there are likely to be

long-term risks to health and wellbeing of

prolonged exposure to demanding working

conditions. Furthermore, evidence from studies

with shift workers indicates that where they

are involved in decisions about how shifts

are organised, they are more likely to accept

the requirements.104 It may be that simply

involving individuals in decisions about the use

of technology improves the likelihood of it being

integrated as intended.

Understanding potential harms

Although enhancements may benefit individuals

or organisations, this must be balanced

against potential harms, some of which we

can predict. For example, the ACMD has drawn

attention to the potential harms of using

anabolic steroids for non-medical purposes on

multiple occasions over the past few years.

These drugs have multiple physiological

effects, most notably anabolic effects (such

as skeletal muscle and bone growth) and

androgenic effects (such as stimulating the

development of the male reproductive system

and sexual characteristics). As a result, they

are associated with a range of potential harms,

including acne, cardiovascular symptoms,

psychological dysfunction (e.g. aggression)

and hepatic dysfunction. Concerns relate

particularly to young people because the use

104 Loudon R & Johnstone R (2009). Occupational health and safety in the modern world of work. In Wilkinson A, et al. (eds). The sage handbook of human resource management. Sage, London.

Social influences

We must also acknowledge the impact that a technology will have on others and the role this will

play in its integration. Successful integration of technology into work or lifestyle does not only

depend on the user, but on the acceptance of the technology by members of their immediate

social or work network. Public acceptance of technologies is one of the most significant challenges

to their translation into everyday practice. For example, if some students use cognitive enhancers

to aid examination performance, this will impact on their peers, who may not see the practice as

acceptable.


42


of anabolic steroids can potentially disrupt

the normal pattern of growth and behavioural

maturation. Where technology is concerned,

the risk of malfunction is clearly a concern.

For example, if an exoskeleton is used in the

workplace to aid heavy lifting, a malfunction

during operation could cause significant

danger to the user and to those around them.

Vulnerability to computer viruses may also be a

risk that needs to be explored further for some

of the enhancements discussed, particularly

where implanted devices become increasingly

sophisticated to the level of simple computers.

There are also less predictable risks of which we

are not specifically aware, but can acknowledge

may exist. Long-term studies exploring the use of

cognitive enhancers in healthy individuals do not

currently exist, for example, and it is very difficult

to collect data on side effects where technologies

are used in more recreational settings.

The increase in online pharmacies means that

more individuals are sourcing prescription

pharmaceuticals from potentially unregulated

sources, which could be out of date, substandard

or counterfeit. They will also be supplied without

appropriate medical advice, meaning that

potential drug interactions will not be assessed

and advice will not be given, or monitoring

performed, to ensure correct use. Incorrect use

could lead to problems: for example, the action of

methylphenidate (used in the treatment of ADHD)

on the dopaminergic system brings the risk of

addiction if it is taken improperly or in high doses.

A poll performed by the journal Nature, to

explore readers’ use of cognition enhancers,

found that one-third of the drugs being used

for non-medical purposes were purchased

online.105 There is also an increase in the

prescription of such drugs.106 This is partly

linked to the medicalisation of human

conditions previously not categorised as

medical problems. We are seeing a steady

increase in prescription rates for stimulants

and an increased range of circumstances under

which individuals can gain a prescription from

a doctor.107 For example, modafinil is approved

for treatment of shift work disorder in the USA,

but clearly the definition of shift work could

encompass many different work patterns.108

Although these drugs may bring benefits to

users, with and without illness, the long-term

side effects of such drugs, and in fact most

human enhancement technologies, in healthy

individuals are unknown. These effects may

be different for young people whose brains are

still developing. If healthy individuals, young

or old, are going to use these drugs, long-term

studies are desirable. Such studies present

obvious ethical questions and it is thus difficult

to gain approval.

There is also a future risk that individuals could

inadvertently become ‘over-enhanced’.109

For example, if cognitive enhancers improve

memory too much, people could lose

their natural ability to suppress unwanted

memories. Alternatively, if many individuals

use the same enhancers, we run the risk of

becoming a homogeneous society that does

not benefit from diversity. On the other hand,

enhancements may enable greater diversity

in some occupations, as discussed below in

relation to equity and fairness.

Much of the science in this area is still

experimental or speculative, making it hard

to provide accurate risk–benefit assessments

on which reliable judgements can be based.

Flexibility, continuous monitoring and the

opportunity for re-assessment of any decisions

is, therefore, vital.

105 Maher B (2008). Poll results: look who’s doping. Nature 452, 674–675.106 Parliamentary Office of Science and Technology (2007). Better brains. http://www.parliament.uk/briefing-papers/POST-PN-285.pdf107 Ibid.108 Food and Drug Administration (2010). Medication guide: Provigil. http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020717s030s

034s036MedGuide.pdf109 Greely H (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature 456, 702–705.

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In addition, discussions are needed around

the extent to which the use of enhancements

is a decision for the employer, the employee

or both. This is discussed further in relation

to regulation and policy in Chapter 6.

Potential harms will need to be a key

consideration in determining the most

appropriate regulatory approach.

Understanding the issue

In many cases it is difficult to understand

how enhancers are, or might in future be,

used in practice, particularly for applications

to take individuals ‘beyond the norm’. The

ACMD reported that it is currently very difficult

to determine how many people make use of

anabolic steroids for non-medical purposes.110

Much of the research into cognitive enhancers

has been conducted in highly mobile groups,

such as senior academics, or groups that

require short, intense bouts of concentration,

such as students sitting examinations, and

even studies within these populations yield

mixed results. The extent to which such

research represents the wider working

population is unclear.

Dr Ilina Singh, Reader in Bioethics and Society

at the London School of Economics and

Political Science, described the preliminary

findings of the UK Smart Drugs Study.111

The project investigates students’ attitudes

and experiences in relation to smart drugs

and cognitive enhancement, with the aim of

collecting empirical data about the prevalence

and practices on university campuses.

The project is currently in its early stages,

but initial student focus groups suggest that

most students have no personal experience

with smart drugs; they do not perceive caffeine

to be a smart drug, cannot name any cognitive

enhancers except Ritalin (methylphenidate) and

are sceptical about the efficacy of smart drugs.

The reasons for this are still under investigation

and further data are being sought by way of a

national survey. However, this highlights the

uncertainty around the use of enhancement

technologies in practice. Perhaps it is only within

the most competitive student environments that

cognitive enhancers are attractive.

To evaluate how enhancement technologies

might impact on individuals’ lives, there is

a clear need to assess levels of awareness

and use accurately. Such an assessment

does not currently exist, either within the

population at large or in the context of work

more specifically.112

Analysis of use must be supported by an

understanding of the factors that might

influence public perception of novel

technologies. Dr Singh told the workshop that

the interdisciplinary approach of empirical

bioethics can inform such analysis. It brings

together philosophical and empirical fields

to improve the practical relevance of moral

evaluations. Thus, we can identify broad

questions that we must understand if we are to

mobilise and enable individuals to assess their

own views on novel technologies. This might

include the following:

• The ethical concerns that arise from

novel technologies.

• How individuals view these concerns.

• How individuals treat these concerns in

their everyday lives, for example when

there is a conflict with underlying values.

• The social drivers that impact on

integration of novel technologies in society.

• The role of government and regulatory

processes in enabling individuals to resp

ond appropriately, for example by making

informed choices.

• The impact of the use of novel technologies

on society.

110 Advisory Council on the Misuse of Drugs (2010). Consideration of the anabolic steroids. http://webarchive.nationalarchives.gov.uk/+ http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/acmd1/ anabolic-steroids-report/anabolic-steroids?view=Binary

111 For more information: http://thesmartdrugstudy.com/112 Ragan CI, Bard I & Singh I, on behalf of the Independent Scientific Committee on Drugs (in press). What should we do about student use of

cognitive enhancers? An analysis of current evidence. Neuropharmacology, http://dx.doi.org/10.1016/j.neuropharm.2012.06.016


44


Of course, there are two potential levels

of acceptance that need to be considered:

accepting the concept of enhancement in

general and then making decisions about

specific enhancement technologies.

For example, willingness to enhance is likely

to be related to how fundamental a particular

trait is perceived to be to one’s sense of self;

emotions and traits such as kindness are

seen as more fundamental and thus less

of an acceptable target to enhance.

We need to evaluate the kinds of attitude

that exist and how attitudes and motivations

differ among different groups. We must try to

understand how the various enhancements

are designed to be used, for example specific

practical questions such as when, how, in what

combinations and the potential long-term

consequences. There is currently a lack of fora

for education, engagement and debate, but it is

very likely that awareness of these technologies

will rise, particularly given that media interest

in the subject is increasing.

Fairness, coercion and disability

Fairness and equity

Enhancement could enable more people to

work at their full biological capacity and to

meet the necessary entry requirements for

an occupation, which could result in a rise in

standards or potentially greater opportunity

and diversity at work. Individuals with lower

cognitive abilities tend to have less choice of

occupations, but enhancement may enable

them to compete and thus have greater choice.

For example, where an occupation requires

excellent memory to qualify and practice,

enhancements that improve this faculty

could facilitate increased diversity within that

profession as it becomes more accessible. Of

course, this is dependent on how different

enhancements affect different people and on an

individual’s ability to access new technologies.

Participants highlighted that one of the

biggest questions relating to the use of human

enhancement technologies is that of who funds

their provision. Enhancement technologies,

particularly in the case of many physical

enhancements, are expensive and are likely

to remain so. If they are available to buy and

are not subject to state support, those with

more money will be able to purchase a greater

number and sophistication of enhancements. If

those technologies enable better performance,

they will further the advantage of those people

and increase the social division between those

who have access via financial resources and

those who do not. The competitive nature of

work means that this could have significant

consequences for the employment prospects of

those less able to self-fund enhancement.

Where technologies are seen as health

interventions, in countries such as the UK,

citizens may expect provision through the

National Health Service. However, changing

demographics, the ongoing economic recovery

and the widening range of available healthcare

technologies all remind us that any health

system, the UK’s included, is subject to a

finite budget. Such a budget will not stretch

to providing all technologies to all individuals.

Added complexity is also driven by the

medicalisation of human conditions and the

rising use of prescription drugs from other

sources, which will blur the boundary between

what was previously seen as medical need and

what is in fact enhancement of the healthy.

This, of course, raises questions that relate

to state provision.

Coercion and freedom

One of the key issues raised in relation to

enhancement technologies is the potential

for social pressure to lead individuals to be

‘coerced’ into using enhancers.113 This applies

particularly to work as it is an inherently

competitive activity; both at an organisational

level, for example where companies compete

113 Morein-Zamir S & Sahakian BJ (2007). Professor’s little helper. Nature 450, 1157–1159.

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for business or to achieve a particular goal;

and at the level of the employee, for example

where the application process for a job is

intrinsically competitive.

At an individual level, we have already

discussed how awareness of enhancement

technologies may currently be limited to

particular populations. This in itself may be

disadvantageous to others. In addition, if an

individual’s peers are enhancing themselves

in some way, people who do not want to

use enhancers for whatever reason could be

coerced into doing so, with implications for

individual freedom. An online poll in the journal

Nature into the use of cognition-enhancing

drugs found that 86% of respondents thought

that healthy children under the age of 16

should be restricted from using them, but 33%

of respondents said they would feel pressured

to give cognitive-enhancing drugs to their

children if other children at school were taking

them.114 A national programme of public

engagement commissioned by the Academy of

Medical Sciences in 2007, with support from

the Government’s Sciencewise programme,

revealed concerns that the use of cognitive

enhancers by healthy adults would exacerbate

an already over-competitive culture.115

Participants discussed how pressure might

also be felt from employers, both implicitly

and explicitly. Economics and globalisation

are currently driving up competitiveness. In

particularly target-driven atmospheres that

look to maximise productivity, an employer

could require employees to use enhancers

(unless prohibited by regulation). Even if this

is not explicitly the case, if expectations placed

on employees are based on the performance

of those using enhancers, then employee

choice will be compromised. For example,

expectations on lorry drivers could in future be

based on the number of hours for which their

awareness levels are sufficient with the use of

a cognitive enhancer. Or individuals in labour-

intensive jobs, perhaps baggage handlers or

construction workers, could be required to do

work that would be much more easily performed

with enhanced strength. This again relates to

the potential danger of using enhancement

technologies to compensate for increasingly

intolerable working environments. Another

source of pressure could be the development of

technology itself. Individuals may in future feel

the need to enhance themselves to cope with

enhanced technology, and if this technology is

used in the workplace, this pressure will only

intensify. The potential role of regulation in such

circumstances is discussed further in Chapter 6.

Disability and normality

Employment rates among individuals with a

disability that limits their daily activities (known

as DDA disabled) are significantly below the

national average for those without a disability.116

Therefore, when considering implications for

the future of work, enabling disabled people to

enter, or continue to participate, in the workforce

is clearly an important potential outcome of

many of the technologies discussed. In addition,

disabilities, for example in hearing or mobility,

become more prevalent in older individuals

and such people will increasingly remain in

work in the future.

The workshop considered technologies that

are both restorative or can take individuals

‘beyond the norm’, a distinction that Dr Jackie

Leach Scully, Reader in Social Ethics and

Bioethics and Co-Director of the Policy Ethics

and Life Sciences Research Centre at Newcastle

University, reported could have beneficial

outcomes. Previously, regulatory decisions were

considered in terms of defining what was (and

was not) permissible in terms of therapy and

enhancement. Such a distinction requires a

definition of ‘normality’, which

114 Maher B. (2008). Poll results: look who’s doping. Nature 452, 674–675.115 Academy of Medical Sciences (2007). drugsfutures: public engagement on the future of brain science, addiction and drugs.

Academy of Medical Sciences. London. http://www.acmedsci.ac.uk/p48prid47.html116 Office for National Statistics (2011). People with disabilities in the labour market – 2011.

http://www.ons.gov.uk/ons/dcp171776_242963.pdf


46


Dr Scully reported was not only difficult, but

also unethical. Referring to enhancement in

general destabilises the idea of there being a

single norm—instead implying that there is a

norm for individual people. Thus, rather than

requiring us to define normality, this might

introduce greater flexibility towards any people

whose embodiment differs from the standard

and consequently the possibility of a radical

rethinking of what ‘normality’ might look like,

which could have positive outcomes.117 Of

course, with greater availability of restorative

technologies, there may be implications for

those who are unable to make use of these

technologies, or who do not wish to do so.

Individuals who ‘acquire’ disability later in

life are likely to have stronger motivation

to restore their ability. However, for many

disabled individuals, if they were born with a

disability or developed it at a young age, living

with their current abilities is their normality.

Society and employers have a legal obligation

to accommodate disability. There may be no

desire on the individual’s part to alter this, but

if the means exist by which they could, it may

become difficult or even unacceptable in the

view of society, for them to choose not to, and

this could eventually have implications for the

ongoing level of the support the state feels able

to provide.

Issues that relate to equity and fairness may

be exacerbated among disabled individuals.

Lower employment rates within this group

affect the means by which they are able to

pay for an enhancement. Also, although there

is a legal obligation on the state to provide

some forms of support to disabled people,

this will be challenged by interventions that

are restorative but that are indistinguishable

from enhancing ones. Examples such as

methylphenidate (commonly known as Ritalin)

are already relevant here because individuals

clearly exist along a scale of abilities,

and defining a single point beyond which

someone is considered to suffer from ADHD

is very difficult. Definitions in this realm are

notoriously problematic. If we take sight as an

example, when older people choose to correct

a decline in visual perception, it is not clear

whether this is restoration or enhancement,

given that such decline is common among their

peers. Decisions will need to be made whether

to extend provision to all or restrict it to

those considered disabled. In the latter case,

subsequent decisions about how to define

eligibility will be difficult and may counter any

blurring of the boundary.

Dr Scully expressed concern that the

development and use of enhancing

technologies among disabled individuals could

lead to a regression in how disability is viewed.

Over the past two decades, there has been a

shift from the so-called ‘medical’ or individual

model of disability, where the ‘problem’ is

something wrong with the person, to various

forms of social–environmental models, in

which physical or attitudinal barriers of society

play a role. The social model has explicitly

become part of UK disability policy. However,

the availability of technologies that are

perceived to ‘fix’ a disabled individual could

impact on the positive change in attitudes,

with a reversion to the ‘individual problem’

view of disability that places the responsibility

to adapt with the disabled person (e.g.

expecting them to provide the assistive

technology so that they are competitive in

the market place). The risk that technology

may be seen as a means by which individuals

can endure increasingly intolerable working

conditions is again significant here. Many

disabled people would be able to participate

in work without restorative intervention if, for

example, there was greater tolerance to their

requiring shorter working days or working

more slowly on some aspects of work.

117 Scully JL & Rehmann-Sutter C (2001). When norms normalize: the case of genetic ‘enhancement’. Human Gene Therapy 12, 87–95.

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Consequences for societal values

There has been considerable debate around how

enhancement would impact on individuality and

identity, for example around whether there are

risks to one’s sense of identity and perception

of ‘self’ when making use of an enhancement,

and particularly if individuals start to make

use of multiple enhancements.118,119 This may

have some particular manifestations in the

context of work. For example, there may be

implications for our feeling able to take credit for

our achievements or for others acknowledging

the success of individuals, which might be

accompanied by effects on societal appreciation

for virtues such as motivation and hard work.

Enhancement may also produce shifts in

the perception of various occupations.

If an occupation requires a skill that can be

acquired through the use of enhancement

technologies, it may lose status compared

with those perceived to require skills that are

less open to acquisition. Public engagement

commissioned by the Academy of Medical

Sciences in 2007, to explore views on the use

of cognitive enhancers, revealed that the effort

and motivation involved in learning are seen as

having intrinsic value. There was a perception

that this value would be reduced with the use

of cognitive enhancers, consequently devaluing

‘normal’ human achievements.120

118 Farah, M. et al. (2004). Neurocognitive enhancement: what can we do and what should we do? Nature Reviews Neuroscience 5, 421–425.119 Morein-Zamir S & Sahakian BJ (2011). Pharmaceutical cognitive enhancement. In Illes J & Sahakian BJ (eds) (2011). Oxford handbook of

neuroethics. Oxford University Press, Oxford, UK.120 Academy of Medical Sciences (2007). drugsfutures: public engagement on the future of brain science, addiction and drugs.

Academy of Medical Sciences. London.


48


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What are the general policy implications?

The use of enhancement technologies in the

context of work raises a diverse and potentially

widespread range of questions. Although some

aspects of technological development, such as

memory capacity, are fairly predictable, this

is not the case for all fields. In addition, we

cannot foresee all of the technologies that will

be used and applied to work. Further, not only

will the field of human enhancement evolve,

but so will the world of work. The concept of

work as a collective activity in which individuals

effectively sell their services to an employer

is relatively new compared with the idea of

enhancing one’s abilities. We are now seeing

further transformation in terms of, for example,

harnessing collective intelligence, and in 50

years’ time work is likely to look very different

to its current form. We must develop a better

understanding of work and how it is performed

if we are to identify potential impacts of

enhancement technologies sufficiently. Not

only this, but we must appreciate the particular

instances where employees’ and employers’

interests diverge, particularly where there are

implications beyond work, for example

on personal life.

Reflecting on the possible uses of enhancement

technologies, Professor Jonathan Montgomery,

Professor in Health Care Law at the University

of Southampton and incoming Chair of the

Nuffield Council on Bioethics, summarised three

broad policy drivers that might influence the

use of enhancement technologies:

• Reducing the impact of demographic

changes and disability on individuals’ lives.

Enhancement may help us overcome these

challenges, but debate will be needed to

determine to what degree it should be part

of the solution.

• Equality of opportunity and improved

productivity. Many of the technologies

identified at the workshop could address

issues of opportunity and enable improved

productivity. Again, enhancement cannot

replace endeavours such as education and

we must carefully consider the extent to

which enhancement should form part of the

solution.

• Infrastructure around innovation.

Enhancement technologies will encounter

significant pre-existing challenges to

innovation, such as the regulation of

medical devices and the slow rate of

adoption of new technologies in healthcare.

This evolving field brings numerous challenges

with which policy-makers must contend.

Not only this, but as Professor Brian Collins

FREng, Professor of Engineering Policy at

University College London and former Chief

Scientific Adviser to the Departments for

Transport and Business, Innovation and Skills,

highlighted, policy decisions are based on

multiple considerations; although science

and engineering are important, decisions are

6 Policy and regulatory implications

Overview

The use of enhancement at work raises several policy issues and potential regulatory

challenges, such as whether enhancements should be mandatory, encouraged, permitted

or prohibited, and whether this varies in different circumstances. The context of work may

be unique because employees are in a vulnerable position and because work is inherently

competitive. A degree of flexibility will be required in the selection of appropriate regulatory

approaches and ongoing monitoring will be essential.

6 POLICY AND REGULATORY IMPLICATIONS

50


complex and driven by, for example, personal

perspectives and experiences. Ongoing

dialogue between policy-makers and individuals

from across disciplines is therefore critical to

efforts to monitor what the future of work might

look like and to progress policy appropriately.

This is necessary at both a national and

international level.

Policy issues concerning enhancement

technologies relate to claims that public

policy and resource decisions are required.

As always, a key question is around whether

emerging enhancement technologies raise

any new policy questions, compared with past

examples of novel technologies. Professor

Montgomery believes that many of the potential

dilemmas have been addressed in previous

contexts. For example, parallel questions

relating to accessibility and claims for public

funds were previously raised in relation to

in vitro fertilisation (IVF) and issues around

surveillance that might relate to life-logging

have been discussed in relation to the growing

use of closed-circuit television.

A particular challenge of many of the

technologies lies in the fact that cost–benefit

assessments will apply across different

government departments. For example,

the benefits of restorative technologies are

likely to be of interest to the Department of

Health, both health and social care, but also

to, for example, the Department for Work

and Pensions. Participants noted that some

enhancements can be considered ‘spend-to-

save’ technologies where benefits will be seen

across government departments; decision-

making processes must reflect this.

Participants highlighted the difficulties in

gathering data to inform policy on human

enhancement. Studies on the use of cognitive

enhancers in healthy individuals face challenges

in passing ethical approval, data to support

the use of new devices is not required for

marketing approval as it is for drugs, and the

use of enhancers often occurs in an unregulated

atmosphere, such as through online drug

purchases.

How might enhancement be regulated at work?

When considering the policy, and particularly

regulatory, implications of human

enhancement, it is important to consider both

public and private policy and to recognise that

these interact. Regulation needs to reflect

societal values, but with the fast pace of

technological progress it can often lag behind

developments, particularly in the case of new

devices, which are subject to less regulation

than drugs. Given the increasing market for

devices, including in the field of enhancement,

it is critical that we consider carefully what the

most appropriate regulatory structure might be.

We must also consider whether the context of

work is different to any other, for example elite

sport or the military.

Broadly speaking, three approaches might be

taken to regulating the use of enhancement

technologies in the workplace: top-down

regulation, i.e. governmental; bottom-up, i.e.

self-regulation where rules are determined by

individual employers (possibly in consultation

with employees); or a hybrid approach of

co-regulation where a top-down element

embeds the public interest but then leaves

other aspects for self-regulatory decision.121

To decide between these approaches, Professor

Roger Brownsword, Professor of Law at King’s

College London, considered where the potential

problems lie with self-regulation. The options

available to employers within this system are

broadly as follows: to require enhancement;

to allow individual employees to choose; or to

prohibit enhancement. People may object to a

system where employees cannot choose how to

121 Brownsword R & Goodwin M (2012). Law and the technologies of the twenty-first century. Cambridge University Press, Cambridge UK. pp 24–45

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51

behave on the grounds that this compromises

human dignity. However, such an objection

could be made to either a top-down or a

bottom-up system.

A second objection might be that enhancements

can cause harm, both to users and non-users.

For individual users, harms may be caused by

using a technology. No technology is zero risk

and individuals must therefore judge acceptable

risk. This judgment of risk will vary with

different circumstances; employees may draw

very different conclusions about risk–benefit

ratios from each other and from their employer,

which could cause difficulties in a system of

self regulation. Of course, a system of top-

down regulation does not guarantee confidence

because regulators will not always be able to

spot potential harms.

Some commentators have pointed out that

individuals who wish to enhance often do

so primarily out of an intrinsic desire to

enhance; any motivation to derive a positional

advantage is secondary.122 However, Professor

Brownsword noted that the nature of work

means that any decision to enhance, whether

by the employer or the employee, is made in an

inherently competitive context; the competitive

advantage gained is inescapable. Thus, work

might be considered to be a unique or, at the

least exceptional, context.

This view gains further strength when we

consider that employees are in a vulnerable

position. As discussed in Chapter 5, there is

a risk that enhancement technologies could

be used as a substitute for improved working

conditions to offset a very challenging working

environment. Even if enhancement is not

formally required, in particularly target-driven

situations that look to maximise productivity,

if an employer’s expectations are based on the

performance of those using enhancers, then

employee choice could be compromised.

And if we extrapolate further, is it possible that

those not using enhancers might eventually

be considered ‘disabled’ in some way? There

is an established view that a labour contract

is different from other types of contract

because of the relations of power and authority

embedded in it.123 In addition, most employees

are unlikely to be in a position where they can

select a job and employer based on their rules

about enhancement. It is likely that any such

rules need to be accepted along with any other

terms of employment.

Thus, in many ways, work represents a unique

context, within which a cautionary regulatory

approach is desirable, with the primary

objective of protecting employees. Self-

regulation is not in the interests of employees

and regulators might therefore need to consider

a top-down approach.

The regulation of enhancement is complex,

as can be illustrated in relation to the use of

enhancements by long-distance lorry drivers.

There might appear to be a relatively simple

regulatory solution to driver tiredness in which

government regulation stipulates maximum

hours for which lorry drivers can work. However:

• If employees in other countries can drive

for longer with the use of enhancements,

the organisations in which enhancements

are not used could be at a competitive

disadvantage. The potential implications

for national economies in such a situation

could be significant. It is entirely possible

that regulatory boundaries will be pushed to

enable enhanced people to work for longer.

122 Harris J (2007). Enhancing evolution: the ethical case for making better people. Princeton University Press, Princeton and Oxford.123 Colling T & Terry M (2010). Work, the employment relationship and the field of industrial relations. In Colling T & Terry M, eds. (2010).

Industrial relations. Wiley, Chichester.

6 POLICY AND REGULATORY IMPLICATIONS

52


• There may be an argument in favour

of lorry drivers using enhancements to

avoid tiredness and minimise danger to

themselves and others, which some might

consider to be almost for altruistic purposes.

The resolution of such dilemmas would require

extensive discussions relating to the rights

of employers, employees, wider society and

stakeholders such as trade unions.

Participants stressed that regulation will

also need to acknowledge that enhancement

technologies are likely to be used for both

restoration and to take individuals ‘beyond the

norm’. The issues are likely to be different for

each. For example, where an enhancement has

uncertainties or risks, these are more likely to

be accepted by the user if they are attempting

to correct a disability. Thus, if restorative

applications might be able to diminish the

boundary between the disabled and the non-

disabled, regulation would ideally promote this

outcome, as well as protect employees. In this

case, it must address two agendas. Of course,

efforts to define any boundary will counteract

any blurring of that boundary. Flexibility in any

regulatory approach will be important in a new

area such as this.

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53

Advances in a range of areas in science and

engineering such as neuroscience, regenerative

medicine and bionics are already enhancing, or

could in the next decade enhance, the physical

and cognitive capacity of individuals in the

workplace. The motivation for the development

of many of the human enhancements discussed

at the workshop has been to restore lost

or absent cognitive or physical functions—

relevant both to increasing access to work for

the disabled and delaying degeneration that

could support an ageing workforce. However,

there are clearly also applications for healthy

individuals, to take them beyond the general

‘norm’. Whether enhancements can reach the

market, within or outside of the health sphere,

will depend on their estimated market potential.

This will be influenced by the regulatory

framework, the time taken to market and the

efficacy and acceptability of the technologies

for users, employers and wider society.

Human enhancement has been discussed

extensively in the academic literature, as have

the various implications (e.g. for equity and

fairness) of new and emerging technologies

that may deliver enhancements. However,

a body of research is lacking both on the

implications of these technologies in the

workplace, and, in many cases, the long-

term health impacts of many of them. This

workshop brought together a multi-disciplinary

group of speakers and participants to explore

this new topic and initiate the debate on the

implications of human enhancement in the

workplace with the aim of identifying areas

requiring further scrutiny.

The power imbalance in the employer–

employee relationship, particularly during

difficult economic times (when employees are

unlikely to be able to pick and choose jobs

based on enhancement polices) was regarded

as raising some unique issues for the debate

about human enhancements, for example

relating to actual or perceived coercion.

Participants highlighted a significant tension

between the potential for enhancements to

‘humanise’ the workplace (improving the work

environment for more effective working for

shorter periods) or to substitute for healthy

working conditions (e.g. encouraging the use of

modafinil to offset the impacts of jetlag rather

than encouraging video conferencing to replace

long-haul flights). A particular example of this

pertained to the use of human enhancement

technologies to facilitate access to work for

disabled people. As one speaker made clear,

the availability of these technologies might

risk undermining the rights of disabled people

to have workplaces designed to accommodate

them, and instead place on them the

expectation to accommodate to the workplace

by using enhancement technologies.

Assessing the potential social, ethical and

regulatory implications of these technologies is

complex because of both the variety of contexts

in which the enhancement technologies could

be used, and the range of likely impacts on the

user and others. This complexity is highlighted

by a sample of the questions identified by

participants that might need to be addressed in

any given situation:

• Does an individual have, or perceive they

have, free choice in terms of using the

enhancement?

• Who is paying, or who can afford to pay?

• Does the decision to enhance or not have

an impact on the wellbeing of others (e.g.

by increasing or decreasing their safety)?

• Does the enhancement significantly increase

the competitiveness of the individual, the

employer or the national economy?

A key question is who should decide how

enhancements should be controlled and

regulated, for example government, employers

or individuals? At the workshop it was proposed

that some element of ‘top-down’ regulation

of enhancements in the workplace would be

required to protect the public interest. However,

7 Conclusion

7 CONCLUSION

54


it was clear that there would be pressure to

permit, encourage or even obligate the use

of enhancements if they could be shown to

increase the safety of others, for example

in the context of medical practitioners or

transport workers. Likewise, there will be calls

for enhancements to be permitted to provide

a level playing field for UK businesses if other

countries are using enhancements. Both these

contexts may lead to the coercion of employees

to take up enhancements.

As previously highlighted, this workshop

represented the very start of the debate on

the implications of human enhancement in

the workplace. It is hoped that this report

will stimulate further debate and research,

particularly to address the ‘known unknowns’

identified by participants. Gaps in our knowledge

could be addressed by:

• Studies on the long-term impacts of the

enhancements on the individual both in

terms of efficacy and harm (e.g. of cognition

enhancers on the developing brain of young

adults). This information is essential in

providing a rigorous cost–benefit analysis for

individuals, policy-makers and wider society.

Here the lower level of scrutiny of devices

(compared with drugs) and the difficulty of

collecting data where enhancements are

used outside the medical setting (e.g. not

prescribed) present particular challenges.

• Rigorous consideration of the complex

ethical and social impacts of human

enhancement in the workplace.

• Deliberative dialogue with users, potential

users and the wider public that is crucial to

guide the development of these technologies

and inform the development of regulation

and guidance.

• The development of a market map of

enhancement technologies that includes

time to market, regulatory considerations,

cost of development, the target of the

technology and the global context.

It was clear from the discussions that

cognition-enhancing drugs present the

greatest immediate challenge for regulators

and other policy-makers. They are already

available without prescription through

internet purchasing, are relatively cheap

and are increasingly being used by healthy

individuals. These might therefore be a high

priority for continued attention. In addition,

digital services and devices with very

significant cognitive enhancing effects are

emerging continuously. They often attract little

regulatory oversight and consequently impact

analyses are rarely undertaken. Studies and

commissioned research are required to assess

rigorously the risks and benefits that will arise

from such services and devices.

Ensuring that the potential benefits of human

enhancement technologies in the workplace are

realised while the risks are minimised will draw

on the combined expertise of the disciplines

represented by the four academies, and require

dialogue with potential users and the wider

stakeholder community. The approaches taken

will need to evolve in response to changes in

the underpinning science and technology as

well as changes in the nature of work.

CHAPTER TITLE

55

Annex I Workshop programme

Welcome and introductionProfessor Genevra Richardson CBE FBA, Steering committee Chair

Developments in science and engineering Chair: Dr Robin Lovell-Badge FRS FMedSci

Cognitive enhancementPharmacological cognitive enhancement –

Professor Barbara J Sahakian FMedSci, Professor of Clinical Neuropsychology,

University of Cambridge

Non-pharmacological cognitive enhancement –

Professor Nigel Shadbolt FREng, Professor of Artificial Intelligence, University of Southampton

Cognitive training and gaming –

Dr Paul Howard Jones, Senior Lecturer in Education, University of Bristol

Respondents

Cognitive maintenance –

Professor John O’Brien, Professor of Old Age Psychiatry, Newcastle University

Non-invasive brain stimulation –

Dr Roi Cohen Kadosh, Wellcome Research Career Development Fellow, University of Oxford

Physical enhancementPhysiology and tissue engineering –

Professor Molly Stevens, Professor of Biomedical Materials and Regenerative Medicine,

Imperial College London

Sensory enhancements – Human Hearing –

Professor Brian Moore FRS FMedSci, Professor of Auditory Perception, University of Cambridge

Sensory enhancements – Human vision –

Dr Matteo Rizzi, Postdoctoral Fellow, University College London

Prosthetics and exoskeletons –

Dr Laurence Kenney, Reader in Rehabilitation Technologies, University of Salford

Respondents

Internal organ enhancement –

Professor Stephen Westaby, Cardiac surgeon, John Radcliffe Hospital, Oxford

Nutrition and performance enhancement –

Professor Ron Maughan, Professor of Sport and Exercise Nutrition, Loughborough University

ANNEX I: WORKSHOP PROGRAMME

56


Opportunities and challenges Chair: Professor Janet Radcliffe-Richards

Commercial opportunities and challenges

Open discussion led by a panel of experts:

• Mr Phil Newman, CEO, PERGALI

• Dr Andrew Elder, Partner, Albion Ventures

• Mr Paul Mason, Head of Development, Technology Strategy Board

• Professor Nikolas Rose, Professor of Sociology and Head, Department of Social Science,

Health & Medicine, King’s College London

Implications for the future of work

Open discussion led by 10 minute reflections from speakers addressing the following topics:

Social and ethical implications –

Dr Ilina Singh, Reader in Bioethics and Society, London School of Economics and Political Science

Disability and normality –

Dr Jackie Leach Scully, Reader in Social Ethics and Bioethics and Co-Director,

Policy Ethics and Life Sciences Research Centre, Newcastle University

Psychosocial perspective –

Dr Pamela Gallagher, Senior Lecturer in Psychology, Dublin City University, Ireland

Principles of regulation –

Professor Roger Brownsword, Professor of Law, King’s College London

Policy priorities, conclusions and closing remarksChair: Professor Genevra Richardson CBE FBA

Professor Brian Collins FREng,

Professor of Engineering Policy, UCL and former Chief Scientific Adviser, Department for Business,

Innovation and Skills and Department for Transport

Professor Jonathan Montgomery,

Professor in Health Care Law, University of Southampton and incoming Chair,

NuffieldCouncilonBioethics

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57

ANNEX II: STEERING COMMITTEE MEMBERSHIP

Annex II Steering committee membership

Professor Genevra Richardson CBE FBA (Chair)

Professor of Law, King’s College London

Professor Paul Edwards FBA

Professor of Employment Relations, Birmingham Business School

Dr Robin Lovell-Badge FRS FMedSci

Head of Division of Stem Cell Biology and Developmental Genetics, MRC National Institute for

Medical Research

Mr Phil Newman

Chief Executive Officer, PERGALI

Professor Barbara Sahakian FMedSci

Professor of Clinical Neuropsychology, University of Cambridge

Professor Nigel Shadbolt FREng

Professor of Artificial Intelligence, University of Southampton

Professor Jonathan Wolff

Professor of Philosophy, University College London

Secretariat

The project secretariat was drawn from across the four academies:

Ms Catherine Luckin Academy of Medical Sciences (lead secretariat until April 2012)

Dr Richard Malham Academy of Medical Sciences (from May 2012)

Dr Rachel Quinn Academy of Medical Sciences (lead secretariat)

Ms Helen Haggart British Academy

Ms Katherine MacGregor Royal Academy of Engineering

Ms Sarah Mee Royal Society

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ANNEX III: WORKSHOP PARTICIPANTS

Annex III Workshop participants

Professor Robin Ali FMedSci Professor of Human Molecular GeneticsUniversity College London

Professor Frans Brom Head, Technology Assessment and Professor in Ethics of Technology Assessment Rathenau Institute and Utrecht University

Professor Roger Brownsword Professor of Law King’s College London

Professor Cary Cooper Distinguished Professor of Organizational Psychology and Health Lancaster University Management School

Ms Helen Clements Health and well-being Directorate, Health and work strategy Department of Work and Pensions

Dr Roi Cohen Kadosh Wellcome Research Career Development Fellow University of Oxford

Professor Brian Collins FREng Professor of Engineering Policy University College London

Dr Claire Craig Deputy Head Government Office for Science

Professor Paul Edwards FBA Professor of Employment Relations University of Birmingham

Dr Andrew Elder Partner Albion Ventures

Mr Fazal Fatah President British Association of Aesthetic Plastic Surgeons

Dr Pamela Gallagher Senior Lecturer in Psychology Dublin City University

Mr James Gallagher Health and Science Reporter BBC News

Mr Oliver Grant Foresight Horizon Scanning Centre

Mr Mike Gray Ergonomist Health and Safety Executive

Professor John Harris FMedSci Sir David Alliance Professor of Bioethics & Director of iSEI University of Manchester

Professor Mark Hawley Professor of Health Services Research University of Sheffield

Mr Graeme Henderson Head of Health and Work Department of Health

Dr Paul Howard Jones Senior Lecturer in Education University of Bristol

Professor Les Iversen FRS Chair Advisory Council on the Misuse of Drugs

Dr Laurence Kenney Reader in Rehabilitation Technologies University of Salford

Professor Tom Kirkwood FMedSci Director, Institute for Ageing and Health Newcastle University

Dr Jackie Leach Scully Co-Director, Policy, Ethics & Life Sciences Research Centre Newcastle University

Dr Robin Lovell-Badge FRS FMedSci Head of Division of Stem Cell Biology and Developmental Genetics MRC National Institute of Medical Research

Mr Paul Mason Head of Development Technology Strategy Board

Professor Ron Maughan Professor of Sport and Exercise Nutrition Loughborough University

Professor Brian Moore FRS FMedSci Professor of Auditory Perception University of Cambridge

Professor Jonathan Montgomery Professor in Health Care Law and incoming Chair University of Southampton and Nuffield Council on Bioethics

Professor Richard Morris FRS FRSE FMedSci Royal Society/Wolfson Professor of Neuroscience University of Edinburgh

60


Mr Phil Newman Chief Executive OfficerPERGALI

Professor John O’Brien Professor of Old Age Psychiatry Newcastle University

Dr Martyn Pickersgill Wellcome Trust Senior Research Fellow in Biomedical Ethics University of Edinburgh

Professor Janet Radcliffe-Richards Professor of Practical Philosophy University of Oxford

Lt Col Simon Redman Medical Futures and Concepts Ministry of Defence

Professor Genevra Richardson CBE FBAProfessor of Law and Steering Committee Chair King’s College London

Dr Matteo Rizzi Postdoctoral Fellow University College London

Professor Nikolas Rose Professor of Sociology and Head, Department of Social Science, Health & Medicine King’s College London

Professor Barbara Sahakian FMedSci Professor of Clinical Neuropsychology University of Cambridge

Alex Salvoni Head Foresight Horizon Scanning Centre

Dr Anders Sandberg James Martin Research Fellow Future of Humanity Institute, Oxford University

Professor Nigel Shadbolt FREng Professor of Artificial Intelligence University of Southampton

Professor Noel Sharkey Professor of Artificial Intelligence and Robotics University of Sheffield

Dr Ilina Singh Reader in Bioethics and Society London School of Economics and Political Science

Professor Molly Stevens Professor of Biomedical Materials and Regenerative Medicine Imperial College London

Professor Lorraine Tyler FBA Professor of Cognitive Neuroscience University of Cambridge

Professor Julian Vincent Honorary Professor of Biomimetics and Scientific Advisor University of Bath and Swedish Biomimetics 3000

Dr Alan Wallace Investment Director Octopus Ventures

Professor Jeremy Watson FREng Chief Scientific Adviser Department for Communities and Local Government

Professor Stephen Westaby Cardiac surgeon University of Oxford

Professor Jonathan Wolff Professor of Philosophy University College London

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GLOSSARY

Aberrant learning: Dysfunctional or maladaptive learning, whereby false or spurious associations

are made. This can be due to the action of drugs.

Attention-deficit-hyperactivity disorder (ADHD): A neuropsychiatric disorder encompassing a

range of behavioural symptoms, including hyperactivity and inattentiveness.

Affective response: An instinctive emotional response to a stimulus or situation.

Age-related macular degeneration (AMD): A condition that affects a part of the retina called

the macula, and a major cause of visual impairment in older adults. It is the most common cause

of retinal degradation in industrialised countries.

Ambient computing: The introduction of computational capacity into a wide range of objects that

share information; for example, a refrigerator with a display that notifies a person of when food or

medications will expire.

Amyloid cascade: A hypothesised mechanism whereby a crucial step in Alzheimer’s disease is the

depositionofaparticularsubstance(amyloid-βpeptide)inbraintissue.

Anabolic: Pertaining to metabolic pathways in the body wherein more complicated molecules are

constructed from simpler precursors. These metabolic pathways also result in generation of new

tissue, such as muscle, which is associated with the abuse of anabolic steroids.

Androgenic: Relating to the development of masculine traits, for example body hair and

muscle mass.

Asymptomatic: A lack of noticeable symptoms. This may mean that the individual concerned is a

carrier for a disease, or a disease is in a ‘dormant’ phase.

Atomoxetine: A drug approved for treatment of attention-deficit-hyperactivity disorder, which

inhibits the reuptake of noradrenaline (a neurotransmitter).

Attentional biases: A set of perceptual distortions wherein attention is disproportionately drawn

by certain stimuli in an environment, resulting in the neglect of additional relevant stimuli when

making judgements.

Augmented intelligence: The achievement of increased intelligence, typically through the use of

information technology.

Augmented reality: Interaction with the physical world that is supplemented with computer-

generated sensory input, for example GPS data or sound.

Bioactive: Materials that interact with or affect (human) cells or tissues.

Glossary

62


Biofeedback: The process of feeding back to an individual information regarding their

physiological activity, for example brainwave or muscle contraction data, acquired using precise

instrumentation. Biofeedback is being increasingly used in prosthesis control.

Biological trade-offs: A biological trade-off occurs when increasing adaptation and optimisation

of one aspect of an organism’s function necessitates the worsening of another.

Bionic limbs and exoskeletons: Mechanical or electrical devices that supplement naturally

occurring human body parts.

Bottom-up regulation: See Self-regulation.

Brain stimulation, deep brain stimulation: Brain stimulation involves touching or activating

specific parts of the brain with electricity, magnets or implants. Deep brain stimulation involves

the implantation of electrodes in the brain that, like a pacemaker, are powered and controlled by a

generator implanted in the chest.

Brain-computer interfaces: A direct link between a brain and an external device, which enables

communication and control without user movement by inferring intent from direct measurements

of brain activity.

Cholinesterase inhibitors: Drugs that inhibit the reuptake of acetylcholine (a neurotransmitter)

by neurons. Their use can be effective in managing the symptoms of Alzheimer’s in early stages or

moderate cases of the disease.

Cochlea, cochlear implants: The cochlea is the part of the inner ear that converts vibrations

(usually from sound waves in the air, via the eardrum and middle ear bones) into nerve impulses.

Cochlear implants are devices for the profoundly deaf or severely hard of hearing that provide

useful representations of sounds. The implant consists of an external portion with microphone(s)

that sits behind the ear and a second portion that is surgically placed under the skin, which filters

and converts the signals into electric impulses, sending them to electrodes wound through the

cochlea allowing them to be transmitted directly to the brain via the auditory nerves.

Cognition: flexibility, impairment, maintenance, training: Cognition describes a set of mental

processes including memory, problem solving, decision making and attentiveness.

Cognition enhancing drugs: Drugs that modulate cognition.

Collective cognition: Cognition performed by a group of individuals through their communication

and collaboration.

Compute complexity: The compute complexity of an analysis describes the computing resources

required to perform the analysis.

Computing fabric: Interconnected computer processors and data storage that are used to

perform computational tasks.

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Contrast sensitivity: A measure of the ability to see detail at low contrast, i.e. the ability to

see the difference between components in the visual field when there is little variation in their

brightness.

Crowd-sourcing: Performing a task or collecting data through the efforts of multiple volunteers.

This is increasingly used in online information sharing, for example Wikipedia.

Decision support systems: Computer programs and data used to assist analysis and decision-

making.

Deliberative dialogue: A process for seeking shared understanding of a problem and identifying

common ground for action, including potential compromises, within a diverse group. The process is

led by a trained facilitator.

Dementia: A group of symptoms describing pronounced (i.e. beyond the common effects of aging)

decline in the brain and its functions. There are two broad forms: static dementia and progressive

dementia, with the latter worsening over time.

Developmental dyscalculia: A learning disability specifically affecting arithmetic capability that

is present from childhood. It is thought to be a brain disorder with inheritable genetic causation,

although environmental factors such as teaching and deprivation have also been implicated.

Dopamine receptor, dopaminergic reward system: Dopamine is a natural neurochemical

responsible for reward-driven learning. Some highly addictive drugs act on dopamine systems in

the brain.

EarLens system: A hearing system wherein sound is picked up by a microphone in or near the

ear canal, and audio signals and power are transmitted by a laser to a receiver resulting in a

transducer vibrating the eardrum directly.

Endogenous glycogen stores: Reserves of carbohydrates (sugars) produced from excess

ingested sugars and stored inside the cells of liver and muscle tissue. They are created or used to

maintain levels of blood glucose.

Episodic memory: The memory for the what, where and when of specific events or experiences.

An example is remembering where you have parked your car. The hippocampal formation, a region

of the brain affected early in Alzheimer’s disease, plays a critical role in episodic memory.

Executive functions: Cognitive processes involved in the conscious and directed planning and

execution of daily activities, for example problem solving and multi-tasking.

Functional Magnetic Resonance Imaging (fMRI): A technique which detects changes in blood

flow to specific areas of the brain, which are used to infer changes in neural activity in those areas.

Foot drop: A condition wherein nerve damage or muscle paralysis leads to an inability to raise the

forefoot.

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Foveola: A point in the retina of the eye that contains densely packed photoreceptors, therefore

potentially the part of the retina responsible for the highest visual resolution.

Gene supplementation: The insertion of corrective genes into the genome of an individual with a

genetic disease. Also referred to asgene therapy.

Gene transfer: The insertion of new segments of DNA into a host cell’s genome.

Germ-line gene modification: Making inheritable genetic changes, achieved by engineering

either the cells responsible for offspring (germ-line cells) or very early stage embryos.

Goal theory: A theory which states that setting goals and achieving them is the main driver of

human motivation.

Global Positioning System (GPS): A satellite-based navigational system. GPS receivers are a

common feature of modern mobile electronic devices.

Growth factor: A naturally occurring substance that can stimulate aspects of a cell’s behaviour

such as to grow and proliferate.

Human enhancement: This term encompasses the use of a range of approaches or endeavours

to modify aspects of human function. The joint academies’ workshop was concerned with both

restoring an impaired function to previous or average levels, or raising a function to a level

considered to be ‘beyond the norm’ for humans. This report considers all forms of enhancement

that directly alter the individual, but excludes alterations to the wider environment that enhance

human interactions with it. It is important to note that there is no consensus on how and whether

humans might be ‘improved’, or that only positive outcomes will arise.

Immersive technology: Technology that creates a sense of immersion by blurring the line

between the physical and virtual world. These technologies typically require the incorporation of

multiple components, for example gesture-based control systems and 3D displays.

Inherited retinal degeneration: Inherited retinal degeneration is commonly attributed to

changes in genetic sequence or gene regulation, often for the gene encoding the light-sensitive

protein rhodopsin.

Intellectual property: Property that results from creations of the mind. Legal rights to this

property may be asserted through patents, copyright or trademarks.

Intragastric infusion: Supply of a liquid directly into the stomach using a tube, for example ‘tube

feeding’.

‘in vivo’ bioreactor: Using the body’s healing mechanisms to engineer new tissue. In the case

of bone, this was achieved by the careful engineering of an artificial space between tissues. More

generally, this term can refer to the production of any cells or proteins in an animal.

Jetlag: A sleep disorder resulting from fast long distance travel between time zones. Also known

as desynchronosis.

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Life logging: The continuous capture of data pertaining to one’s life. This can now be more

practicably achieved using computational means, for example portable cameras and/or wireless

devices.

Market map: An analysis of a market segment that aids the positioning of a product relative to its

competitors. This is usually based on two dimensions of consumer perception, for example quality

versus price.

Memory: Memory refers to the processes that encode, store and retrieve information. See also,

memory capacity, memory encoding, episodic memory and working memory.

Memory capacity: The amount of information that can be handled by memory.

Memory encoding: The receiving, processing and combining of information, for example visual

stimulus, resulting in the generation of a memory.

Mental capital: A term describing an individual’s cognitive and emotional resources, including

capacity for learning and social skills.

Methylphenidate: A stimulant drug that inhibits the reuptake of dopamine and noradrenaline

(both neurotransmitters) into neurons. More commonly known by the trade name Ritalin.

Mixed reality: An environment that merges the real with virtual worlds, such that physical and

digital objects interact in real time.

Modafinil: Modafinil is a central nervous system wake promoting agent used for the treatment of

excessive daytime sleepiness. It is commonly known by the trade name Provigil, and is used in the

treatment of narcolepsy. Modafinil has effects on many neurotransmitters in the brain. Its cognitive

enhancing effects are thought to be mediated primarily by noradrenaline and dopamine.

Motivation theories: Multiple theories have been developed in attempts to rationalise the

mechanisms of human motivation. These are variously based on principles such as minimising

pain, avoiding death or attaining a particular object or outcome.

Multi-channel compression: An operation that brings the frequencies and volumes of sounds

audible to an unimpaired ear into the range audible by the user of a hearing aid. Multi-channel

techniques are considered to result in better outcomes than single channel techniques.

Myocardium: The muscular middle layer of the heart wall, contraction of which generates the

heartbeat.

Neurochemical: A substance that affects the nervous system.

Neurodegeneration: The progressive loss of neuronal structure or function, which can result in

neurodegenerative diseases such as Parkinson’s and Alzheimer’s.

Neuronal excitability: The ability of a neuron to generate and propagate nerve impulses (action

potentials).

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66


Neuropsychiatry: A medical discipline concerned with only those mental disorders that can be

strongly associated with neurological conditions, such as head injuries.

Noradrenaline: A hormone and neurotransmitter released naturally by nerve cells, effecting ‘fight

or flight’ responses such as increased heart rate.

Nutritional supplements: A mixture of nutrients, such as vitamins or amino acids, used to

supplement components that may not be sufficiently consumed in an individual’s diet. They are

differentially defined as foods, drugs or health products in different nations.

PageRank: An algorithm used by the Google search engine to analyse interlinked web pages with

the purpose of determining their relative importance.

Pervasive computing: An environment wherein almost all objects in the physical world have

computational capacity and are interconnected.

Pharmacogenomics: The study of the influence of an individual’s genetic variation on their

response to pharmaceuticals.

Photoreceptors: Specialised neurons found in the retina that convert light input into nerve

signals. There are two main types, rods and cones.

Placebo: Used in controlled clinical trials, the placebo is a ‘dummy’ treatment administered to the

control group. This controls for the placebo effect, wherein simply the administration of a treatment

can result in a psychosomatically-mediated improvement in conditions. A placebo therefore allows

the specific and nonspecific effects of the experimental treatment to be distinguished.

Plasticity: The ability to adapt to changes in the environment.

Pluripotent cells: A type of stem cell capable of producing any foetal or adult cell type.

Prefrontal cortex, prefrontal cortical network: The brain region most implicated in performing

executive functions, and closely linked to individual personality.

Prostheses: Artificial devices used as replacement body parts, such as a heart valve or limb.

Protein synthesis: An anabolic process wherein protein molecules are synthesised from amino

acids.

Psychosocial: Pertaining to the effect of the social environment on the mind and subsequently the

body. See Box 4 on page 36: ‘The psychosocial perspective’.

Psychostimulation: The effects produced by stimulant drugs, i.e. the inducement of temporary

changes in mental function.

Publics: The plural of public is used to recognise that the public is not homogeneous and contains

sub-sections of society who have particular concerns e.g. patient or campaign groups.

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Real-time ultrasound: A form of ultrasound used to ‘view’ deep muscle contractions in real time.

Recombinant antibodies: Antibodies produced by genetically engineered microorganisms or

animals (notably mice).

Regenerative medicine: A field of research and clinical practice concerned with repairing or

replacing organs, tissues or cells.

Resilient neurodevelopment: Neurodevelopment that responds adaptively to stressful or

traumatic circumstances or events.

Retinal implants: Implants designed to restore visual capacities such as object recognition or

light perception to those who have suffered from degenerative eye conditions. This is achieved by

the implant electrically stimulating retinal cells. Two types of implant are currently being clinically

trialled, for placement both on and behind the retina.

Reverberant: An environment wherein sound persists (echoes), decaying slowly.

Self-regulation: In this context, a system where companies are responsible for regulating their

own behaviour (e.g. through a code of practice) rather than being governed by legally binding

regulations.

Self-regulatory theory: A system for managing personal health, wherein the self-regulation

(desire to get better) of the patient is critical to the implementation of medical advice and resultant

efficacy of the medical treatment.

Semantic Web: A movement, led by the World Wide Web Consortium, promoting the inclusion

of metadata (semantic data) in web pages, to make it easier for users and programs to find and

process data on the web.

Social computation: A branch of computer science that deals with the interface between

computational systems and social behaviours: this can involve either the support of social

behaviour through computational systems, or the use of social groups to carry out ‘computations’.

Sociotechnical: Relating to the interaction between technological systems/technology and social

systems/people.

Somatic gene therapy: The transfer of corrective genes into the somatic (i.e. any cells other

than germ line) cells of a patient. This means that the corrective genes will not be passed on to the

patient’s offspring.

Stance phase: Part of the gait cycle, between the heel striking the ground and the toe lifting from

the ground.

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68


Stem cells: embryonic: Stem cells differ from other cells in two ways: they are unspecialised

yet renew themselves through cell division, and they can be induced to specialise under certain

conditions. Embryonic stem cells can be derived from cells present in the very early embryo, before

they have specialised into a specific tissue type. Research, originally in the mouse, demonstrated

that these cells can give rise to all the cell types of the developing embryo and adult mouse; they

are therefore considered ‘pluripotent’.

Stimulant: See Psychostimulation.

Synaesthesia: A neurological condition in which stimulus in one sense leads to experiences in a

second sense. For example, the month August visually evoking the colour brown.

Synapse: The structure which forms a junction between a nerve cell and another cell, which allows

electrical or chemical signals to be transmitted between the cells.

Synthetic biology: A multidisciplinary branch of biological research and technological

developments concerned with designing novel non-natural biological functions and systems.

Targeted muscle re-innervation: A technique for allowing amputees to control prosthetic limbs

and regain sensory feedback. In muscles, multiple nerves are transferred into the target muscle,

and the multiple signals from these nerves are used to control the prosthesis.

Tau protein: Proteins that normally stabilise sub-cellular structures called microtubules, but when

defective result in dementias such as Alzheimer’s.

Tissue engineering: The improvement or restoration of biological functions using the methods

of engineering, biochemistry and medicine: most commonly the repair or replacement of whole

tissues such as cartilage or bone.

Top-down regulation: A system wherein one entity (e.g. Government) is responsible for

regulating the behaviour of multiple other entities (e.g. a particular sector of industry) often

through legally binding regulations.

Trachea: Also known as the windpipe, this is the tube through which air flows from the larynx to

the lungs.

Transcranial stimulation – magnetic, electrical: Transcranial stimulation is a method used to

stimulate neurons in the brain. This can be achieved non-invasively with electromagnets positioned

above the scalp (transcranial magnetic stimulation), or with electrodes placed onto the scalp

(transcranial direct current stimulation).

Ventricular assist device: A pump used by those with weak hearts to support blood flow and

heart functioning.

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GLOSSARY

Viral vectors: Viruses have evolved highly efficient mechanisms to introduce their genetic

material into cells they infect. Viral vectors are engineered virus particles that exploit these

mechanisms to introduce engineered genetic material into cells (while at the same time any

disease-causing viral genes have been deleted).

Viscoelastic: Having both elastic (returns to original shape after stress) and viscous (resistance

of a fluid to deformation by stress) properties.

Visual cortex: The part of the brain’s cerebral cortex that processes visual information.

Visuomotor: Any movement that arises from or relies on sight.

Working memory: The system that actively holds information in the mind to do verbal and

nonverbal tasks such as reasoning and comprehension, and to make it available for further

information processing.

Academy of Medical Sciences 41 Portland Place London, W1B 1QH

+44(0)20 3176 2154www.acmedsci.ac.uk

The Royal Society 6-9 Carlton House Terrace London, SW1Y 5AG

+44(0)20 7451 2500www.royalsociety.org

British Academy 10-11 Carlton House Terrace London, SW1Y 5AH

+44(0)20 7969 5200www.britac.ac.uk

Royal Academy of Engineering 3 Carlton House Terrace London, SW1Y 5DG

+44(0)20 7766 0600www.raeng.org.uk

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